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One of the most important issues facing the US is our high cost of health care. We have a terribly inefficient system, with the highest costs in the world (reaching 18% of GDP, which is 50% more than in the second most expensive country and close to double the average of the OECD countries), yet with only mediocre results compared to other countries. It is a market-based system, with competing health care providers (doctors, hospitals, and so on) and competing private health insurance companies. However, the extremely wide variation in prices for the same treatments and procedures (often varying by a factor of ten or more) is a clear sign that this market is not working as it should. And those skilled at exploiting these inefficiencies are able to profit handsomely, with CEOs and other senior staff of the major private insurance companies paid well. Indeed, total compensation packages have occasionally even topped $100 million.

Despite so much spending, the US is still far from providing affordable access to health care for our entire population. While the situation improved substantially following the introduction of Obamacare (with the share of the US population without any form of health insurance falling by about 40% after Obamacare went into effect), the Trump administration is doing all it can to reverse these gains.

Faced with these issues, a number of analysts and politicians (Senator Bernie Sanders as just the most prominent) have proposed that the US move to what is termed a “single-payer” system, such as what they have in Canada, France, and a number of other countries. In a single-payer system, doctors, hospitals, and healthcare service providers remain as they are now, as independent and typically private agents serving their patients. The only difference is that there is only one insurer, run as a government agency. This is what the US has in the popular Medicare system, but Medicare is restricted only to those aged 65 and above. Hence in the US context, a single-payer system for all is often referred to as “Medicare-for-All”.

A key question is whether a Medicare-for-All system would reduce the high cost of healthcare in the US. Those opposed to any such government managed programs have argued that costs would rise. And they have issued reports with headline findings that can only be interpreted as being deliberately misleading. For example, in late July, Charles Blahous (a former Bush administration official) issued an analysis through the Mercatus Center of George Mason University (a center that has received major funding from the Koch Brothers) that concluded government spending would rise by $32.6 trillion over ten years under a Medicare-for-All system. This has received a good deal of press coverage, and is being used (as I write this) in a number of ads being televised by Republican candidates in the 2018 midterm elections.

But while worded carefully, this claim is misleading in the extreme. First of all, that such high amounts will be spent on health care should not be a surprise, when added up over ten years. Total US health care spending is expected to reach $3.7 trillion this year, would rise to $5.7 trillion by 2026 if nothing is done, and would total $45.0 trillion over the ten-year period of 2017 to 2026 (using National Health Expenditure data and forecasts, which will be discussed in detail below). The portion of this covered by various forms of personal health insurance (both private and public, such as Medicare, but excluding the military and the VA) is expected to reach $2.7 trillion this year, $4.2 trillion by 2026, and would sum to $33.1 trillion over the ten years 2017 to 2026.

So high amounts will be spent on health care, unless measures are taken to improve efficiency and reduce costs. In per capita terms, the US population will be spending in 2018 an average of $8,190 per person through the various forms of personal health insurance our system currently employs. This is, without question, a lot. It will be an estimated 17.9% of the median wage this year. But if we had the far lower administrative costs that Medicare has been able to achieve for the health insurance it manages directly, instead of the significantly higher administrative costs incurred under a variety of mostly private health insurance plans (discussed below), the average per capita cost would be just $7,480 per person in 2018. There would also be other savings (such as what health care providers will enjoy from a simplified system, which we will also discuss below), but the savings from those sources, while certainly significant, are harder to estimate. The $7,480 figure simply reflects savings from lower administrative costs on the part of the insurers if we were able to achieve what Medicare already does.

Thus the correct question is whether we should prefer sending a check for $8,190 per person to Aetna, Cigna, United Healthcare, and the other insurers (and including what is paid through taxes for Medicare and other publicly managed insurance), or a check for $7,480 just to Medicare under a Medicare-for-All system. The doctors we see would be the same, and the treatments and procedures would also be the same as what we have now. The savings here is purely from more efficient administration of our health insurance. That the check in one case goes just to the government, and in the other to a mix of private and public insurers, should not be, in itself, of consequence. But the Blahous argument, in saying that we cannot afford the $32.6 trillion he forecasts for healthcare spending over ten years, is that for some reason a larger check (of $8,190) to our current mix of insurers is fine while we cannot afford to send instead a smaller check (of $7,480) if that check goes to a government entity. This is silly.

For the nation as a whole, the savings from the greater efficiency of a Medicare-for-All system is substantial. As we will see, it would add up to $204 billion in 2016, had this system been in place that year, growing to $365 billion by 2026. For the ten year period from 2017 to 2026, the savings would sum to $2.9 trillion. This is not a small sum.

This main point is that we should look at the data, and not presume certain outcomes based on ideology or political beliefs. We will thus start in this blog post with an examination of what administrative costs actually are, for Medicare and for private insurance. We will see that the cost for administering Medicare, for the portion of Medicare managed directly by government, is far less than what is spent to administer other health insurance, including in particular private health insurance. There are many reasons for this, where the most important is the relative simplicity and scale of the Medicare system. An annex to this blog will discuss in detail what these various factors are for the different health insurance systems that could be folded into a Medicare-for-All system. We will also discuss in that annex why Medicare is able to achieve its far lower administrative costs, and address some of the arguments that have mistakenly asserted that this is not the case, despite the evidence.

Taking the administrative costs that Medicare has been able to achieve as a base, we will then calculate what the savings would add up to, per year for the US as a whole, under a Medicare-for-All system. The basic result is depicted in the chart at the top of this post, and as noted above, the savings from greater administrative efficiency would rise from $204 billion in 2016 (had the system been in place then) to $365 billion in 2026.

These savings are substantial. But there are also other savings, which are, however, more difficult to estimate. The penultimate section of this post will discuss several. They include savings that will be possible in the administrative and clerical costs at doctor’s offices and at hospitals and other healthcare facilities. Doctors, hospitals, and other facilities must hire specialist staff to deal with the complex and fragmented system of insurance in the US, and the costs from this are substantial. There will also be savings on the part of employers, who must now manage and oversee the contracts they have with private insurers.

A final, concluding, section will summarize the key issues and discuss briefly why such an obvious and large saving in costs has not been politically possible in the US (at least so far). The short answer: Vested interests profit substantially under the current fragmented system, and it should not be a surprise that they do not want to see it replaced. With extra spending in the hundreds of billions of dollars each year, there is a lot to be gained by those skilled at operating in this fragmented system.

B. The Cost of Administering Current Health Insurance Plans

It is often difficult to estimate what costs and savings might be under some major reform, as we do not yet know what will happen. But this is not the case for estimating administrative costs for health insurance. We already have excellent data on what those costs actually are for a variety of different health insurance providers, including Medicare.

The primary sources of the data are the National Health Expenditure Accounts (NHE), produced annually by the Centers for Medicare and Medicaid Services, and the Annual Report of the Medicare Trustees. The current NHE (released in February 2018) provides detailed historical figures on health expenditures (broken down in numerous ways) through to 2016, plus forecasts for many of the series to 2026. And the Annual Report of the Medicare Trustees (with the most recent released in June 2018), provides detailed financial accounts, including of government administrative costs, for the different components of Medicare and the supporting trust funds (with past as well as forecast expenditures and revenues).

Table 19 of the historical tables in the most recent NHE provides a detailed break down of health care expenditures in 2016 by payer (mostly various insurance programs, both public and private). The expenditures shown include what is spent on administration by government entities (separately for state and federal, although I have aggregated the two in the table below), and for what they term the “net cost of health insurance”. The net cost of private health insurance includes all elements of the difference between what the private insurer receives in premium payments, and what the insurer pays out for health services provided by doctors, hospitals, and so on. Thus it includes such items as profits earned by the insurer. For simplicity, I will use “administrative costs” to include all these elements, including profits, even though this is a broad use of the term.

Table 19 of the NHE shows Medicare expenditures for all components of Medicare on just one line. While it shows separately the administrative costs incurred by government in the administration of Medicare (with all of it federal, as states are not involved), and the administrative costs (as defined above) incurred by private insurers for the Medicare programs that they manage, the NHE does not show separately which of those costs (government and private) are linked to which Medicare programs.

For those figures one must turn to the Medicare Trustees Annual Report. Medicare Parts A and B are managed directly by Medicare officials, and provide payments for services by hospitals (Part A) and doctors (Part B). Medicare Part C (also now called Medicare Advantage) is managed by private insurers on behalf of Medicare, and cover services that would otherwise be covered by Medicare directly in Medicare Parts A and B. And the relatively recent Medicare Part D (for prescription drugs) is also managed by private insurers, either as a stand-alone cover or folded into Medicare Advantage plans.

Any such combination of numbers from two separate sources will often lead to somewhat different estimates for those figures that can be compared directly with each other. There might be slight differences in definitions, or in concepts such as whether expenses are recorded as incurred or as paid, or something else. But the figures which could be compared here were close. In particular, the figure for total Medicare expenditures in calendar year 2016 was $678.8 billion in the Trustees report and $672.1 billion in the NHE, a difference of just 1%. Of greater relative importance, the Trustees report has a figure for government administration (for all Medicare programs combined) of $9.3 billion, while the NHE has a figure of $10.5 billion. However, while the difference between these two figures may appear to be large, what matters is not so much the difference between these two, but rather the difference (as a share of total costs) between either of these and the much higher cost share for privately managed insurance (as we will see below). We will in any case run scenarios in Section C below with each of the two different estimates for government administrative costs in Medicare, and see that the overall effect of choosing one rather than the other is not large.

Based on these sources, the costs paid in 2016 under most of the major health insurance programs in the US were:

The table leaves out the health care programs of the Department of Defense and the Veterans’ Administration (as they operate under special conditions, with many of the services provided directly), as well as a number of smaller government and other programs (such as for Native Americans, or worksite or school-based health programs). Those programs have been set aside here due to their special nature. But while significant, the $2,435.3 billion of expenditures in the programs listed in the table account for 89% of the total spent in the US in 2016 on all health care services to individuals covered through either some form of health insurance or third-party payer. While some portion of the remaining 11% could perhaps be folded into a Medicare-for-All system (thus leading to even higher savings), we will focus in this post on the 89%.

The table shows that the administrative cost ratios vary over a wide range, from just 2.4% for the health insurance Medicare administers directly (using the Medicare Trustees figures, or 2.7% based on the NHE figures), up to 37% for the administration of the health portions of Workers’ Compensation. The administrative cost for direct private health insurance is 11.5% on average, while the administrative cost for the privately managed portions of Medicare (Medicare Part C and Part D) is a similar, but somewhat higher, 12.6%.

This wide variation in administrative cost ratios provides clues on what is going on. These will be discussed in the Annex to this post for those interested. Briefly, the programs (other than government-administered Medicare) are complex, fragmented, have to make case by case assessments of whether the claim is eligible (as for Workers’ Compensation plans) or whether the individual meets the enrollment requirements (as for Medicaid and CHIP – the Children’s Health Insurance Program), and do not benefit from the scale economies that Medicare enjoys.

But while such explanations are of interest in understanding why Medicare can be provided at such a lower cost than private and other insurance, the key finding, in the end, is that it is. The data are clear. The next section will use this to calculate what overall savings would be at the national level if we were to move to a system with the cost efficiencies of Medicare.

C. National Savings in Administrative Costs from a Medicare-for-All System

Medicare (for the portion managed directly by government) costs far less to administer than our current health insurance system with its complex and fragmented mix of plans (most of which are privately managed). Only 2.4% of the cost of the portion of Medicare managed directly by government was needed for administration of the program in 2016, while the costs to administer the other identified health insurance programs range between 10.7% (for Medicaid) and 11.5% (for private health insurance) to 37% (for workers’ compensation plans). With $2.4 trillion spent on these health insurance plans (in 2016), the savings from a more efficient approach to administration will be significant.

An estimate of what the nation-wide savings would be can then be calculated based on figures in the NHE forecasts of health expenditures (by health insurance program) for the 2017 to 2026 period (Table 17 of the forecasts), coupled with the Medicare system forecasts provided in the Medicare Trustees Annual Report. Applying the share of administrative costs in the portion of Medicare managed directly by government (2.4% in 2016, but then using the year by year forecasts of the Medicare trustees for the full forecast period), rather than what the administrative cost ratios would have been for the other programs that would be folded into a Medicare-for-All system (private health insurance, Medicaid, CHIP, and Workers’ Compensation), using their 2016 cost ratios, yields the savings shown in the chart above.

Had a Medicare-for-All system been in effect in 2016, we would have saved $204 billion in administration, with this growing over time (with the overall growth in health expenditures over time) to an estimated $365 billion by 2026. The savings over ten years (2017 to 2026) would be $2.9 trillion, and would by itself bring down the cost of health care (for the programs covered) from a ten year total of $33.1 trillion forecast now, to $30.2 trillion with the reform. There would be other savings as well (discussed in the next section below), but they are more difficult to quantify. However, a very rough estimate is that they could be double the magnitude of the savings from the more efficient administration of health insurance alone. See the next section below for a discussion.

The calculations here required a mix of data from the NHE and from the Medicare Trustees report, and as I noted above, the estimates of the cost of government administration in these two sources were not quite the same. The Medicare Trustees report gave a figure for government administrative costs of the overall Medicare system of $9.3 billion in 2016 (and then year by year forecasts going forward to 2026), while the NHE estimate was $10.5 billion in 2016. As shown in the last line of the table above, the $10.5 billion figure would lead to an administrative cost share of 2.7%, compared to the 2.4% figure if the cost was at the NHE figure of $10.5 billion. The savings in moving to a Medicare-for-All system would then not be as large.

But the impact of this would be small. One can calculate what the cost savings would be assuming government administration would cost 2.7% rather than the 2.4% figure in the Medicare Trustees report (with also its forecasts going forward), using the same process as above. The total national savings would have been $199 billion in 2016 rather than $204 billion, growing to savings of $345 billion in 2026 rather than $365 billion. The ten-year total savings would be $2.7 trillion rather than $2.9 trillion. The savings under either estimate would be large.

D. Other Efficiency Savings in a Medicare-for-All System

The $2.9 trillion (or $2.7 trillion) figure for savings over ten years from moving to a Medicare-for-All system comes solely from the lower administrative costs that we know can be achieved in a Medicare type system – we know because we know what Medicare in fact costs. But there are other savings as well that will be gained by moving to this simpler system, and this section will discuss several of them. How much would be saved is more difficult to estimate, so we have kept these savings separate. But some rough figures are possible.

But before going to these other sources of efficiency gains, we should mention one possible source of lower costs which has often been discussed by others, but which I would not include here. It has often been asserted that Medicare pays doctors, hospitals, and other health service providers, less than what other insurance plans pay. But first, it is not clear whether this is in fact true. It might be, but I have not seen reliable data to back it up. The problem is that most of what is paid to doctors, hospitals, and others by private health insurance plans is now at network negotiated rates, and these rates are kept as trade secrets. It is not in the interest of the doctors and other health care providers to reveal them (as it would undermine their bargaining power with other insurers), nor in the interest of the insurance companies to reveal them (as other insurers would gain a competitive advantage in their negotiations with the providers). Indeed, secrecy clauses are common in the negotiated agreements.

In the absence of such publicly available data, one is limited to citing either anecdotal cases, or statements by various health care providers who have a vested interest in trying to persuade Medicare to pay them more. Neither will be reliable.

But second, and aside from this difficulty in knowing what the truth really is, the focus in this blog post is solely on the gains that could be achieved by moving to a more efficient system. If doctors and hospitals are indeed paid less under Medicare, costs would go down, but this would be in the nature of what economists call a transfer payment, not an efficiency gain. Efficiency gains come from being able to do more with less (e.g. administer more at a lower cost). Transfers are a payment from one party to another, with no net gain – the gain to one party is offset by a loss of the same amount to the other.

Excluding such transfers (if they in fact exist), what are other efficiency gains that one would obtain with a Medicare-for-All system (other than the gains from lower administrative costs for the health insurance itself, which we estimated above)? There are several:

a) Doctors offices now need to employ specialists in handling billing, who are able to handle the numerous (and often changing) health insurance plans their patients are enrolled in. These specialists are critical, and good ones are paid well, as they are needed if the doctors want to be paid in full for the services they provided. Based on personal experience, I am often amazed that the staff good at this are indeed able to stay on top of the numerous health insurance plans they must deal with (I find it difficult enough to stay on top of just my own). While essential to ensuring the doctors can survive financially, such staff are a significant cost. While one will still need to ensure proper billing under any Medicare-for-All system, it would be far simpler.

b) Similarly, hospitals and other medical facilities need to employ such specialist staff to handle billing. The same issues arise. They must contend with numerous health insurance plans, each with its own set of requirements, and ensure the bills they file with the insurers will compensate the facilities properly (and from their perspective most advantageously) for the services provided. This is not easy to do under the present highly complex system, and would be far simpler under Medicare-for-All.

c) There are also costs that must be borne by employers in managing the primarily employer-based health insurance system used in the US. The employer must work out which health insurance provider would work best for them, negotiate a complex but critical and expensive contract, and then oversee the insurer to ensure they are providing services in accordance with that contract. Firms must often hire specialist (and expensive) consultants to advise them on how best to do this. With the cost of healthcare so high in the US, these health insurance contracts are costly. It is important to get them right. But all this necessary oversight is also a major cost for the firm.

How much might then be saved from such sources by moving to a more efficient Medicare-for-All system? This is not so easy to estimate, but one study looked at the costs in the US from such expenses and compared them to similarly measured expenses in Canada, which has a single-payer system. As noted above, a Medicare-for-All system is a single-payer system, and thus (along with the other similarities between the US and Canadian economies, such as the similar levels of income) the difference between what the costs are in the US and the costs in Canada for the same services can provide an estimate of how much might be saved by moving to a single-payer, Medicare-for-All system.

The study was prepared by Steffie Woolhander (lead author – Harvard Medical School), along with Terry Campbell, and David Himmelstein, and was published in the New England Journal of Medicine, August 2003. They drew from a variety of sources to arrive at their estimates, and some had to be approximate. The data is also from 1999 – almost 20 years ago. Things may have changed, but with the upward trend in costs over time in the US, the cost shares now are likely even worse. The authors presented the basic figures in per capita terms (and all in US dollars), and I have scaled them up to what they would be in 2016 (assuming the shares are unchanged) in accordance with the overall growth in US personal health care spending (from the NHE accounts).

Note: “Insurance overheads” exclude health insurer profits as well as certain expenses (such as for advertising and marketing).

The first three columns show the estimated spending in per capita terms (and in US dollars) for each category of costs, for the US, for Canada, and then for the difference between the two. US spending is always higher. Thus, for example, for the line labeled “doctors”, the authors estimate that doctor’s offices have to spend an average of $324 per every US resident for expenses related to billing and other dealings with health insurance companies in 1999. The cost in Canada with its single-payer system, in contrast, is on average just $107 per resident (in US dollar terms). The difference is $217 per person, in 1999. Grossing this up to the US population, and rescaled to total health care expenditures in the US in 2016 relative to 1999, the excess cost in the US in 2016 is an estimated $160.6 billion. This is what would be saved in the US in 2016 if doctor’s offices were able to manage their health insurance billings with the same efficiency as they can in Canada.

The other lines show the estimated savings from other sources. The top line is for insurance overheads. The estimate here is that the US would have been able to save $156.9 billion in 2016 if health insurance administration were as efficient as what is found in Canada with its single-payer system. While on the surface this appears to be less than the $204 billion savings estimated (for 2016) if the US moved to a Medicare-for-All system, they are in fact consistent. The estimate in Woolhander, et. al., of the excessive cost of health insurance administration excludes what is paid out in insurance company profits and certain other expenses (such as advertising and marketing). As discussed in the Annex below, insurance company profits can add one-third to administrative costs, so a $150 billion cost would become $200 billion when one uses the same definitions for what is encompassed. The two estimates are in fact surprisingly consistent, even though very different approaches were used for the estimation of each.

Overall, the US would have saved about $400 billion (excluding the savings from lower expenses at the insurance companies) had a single-payer system been in effect in 2016, according to these estimates. That is double the estimated $204 billion in savings from lower administration costs at the health insurers alone, estimated in the section above. These additional cost savings from moving to a Medicare-for-All system are clearly significant, but are often ignored in the debate on how much would be saved from efficiency gains in a Medicare-for-All system. They are (I would acknowledge) rough estimates. They cannot be estimated with the same precision as one can for the savings from the more efficient administration of health insurance alone under a Medicare-for-All system. But neither should they be forgotten.

E. Summary and Conclusion

Medicare is a well-managed and popular program. It is a single-payer system, but currently restricted to those aged 65 and above. And administrative costs, on that portion of Medicare managed directly by government, are only 2.4%. This 2.4% is far below the 11.5% administrative cost share for regular private health insurance, or 12.6% for that portion of Medicare that is managed through private health insurance companies.

And even with such low costs, Medicare is a popular program, where numerous surveys have found Medicare to be more highly rated (including in terms of user experiences with the program) than private health insurance plans (see, for example, here, here, here, and here).

Creating a Medicare-like system to cover also those Americans below the age of 65 would not be difficult. We already have the model of Medicare itself to see what could be done and how such a system can be managed. And we also have the examples of other countries, such as Canada, that show that such systems are not only feasible but can work well. It is also not, as conservative critics often assert, a government “takeover” of healthcare (a criticism also often used in attacks on Obamacare): Under a single-payer system, the providers of health care services (doctors, hospitals, and so on) remain as they are now, as private or non-profit entities, competing with each other in the services they offer.

Nor would an extension of health insurance under a Medicare-like system to those below age 65 lead to issues for the current Medicare system. This has now become an attack line being asserted in numerous Republican political campaigns this fall, including in a signed piece by President Trump published on October 10 by USA Today. This was in essence a campaign ad (but published for free), which fact checkers immediately saw contained numerous false statements. As Glenn Kessler noted in the Washington Post, “almost every sentence contained a misleading statement or a falsehood”.

There is no reason why extending a Medicare-like system to those below age 65 should somehow harm Medicare. The cost for the health insurance for those below age 65 would be paid for by sending the checks we currently must send to private insurers (such as Aetna or United Healthcare), instead to the new single-payer insurer. As noted above, with such an entity copying the Medicare management system and achieving its low administrative costs, we would have been able to reduce the average per person cost of healthcare in 2018 from the $8,190 we are paying now, to $7,480 instead, a savings of $710 for each of us. That $7,480 would still need to be paid in, but it is far better to send in $7,480 to the single-payer (for the same health care services as we now receive) than to send in $8,190 to the mix of insurers we now have.

Furthermore, these savings are solely from the more efficient administration of health insurance that we see can be done in Medicare. There will also be very substantial savings from other sources in a Medicare-for-All system, including in what doctors and hospitals must now spend to deal with our currently highly fragmented and complex health insurance system, and savings by employers in what they must spend to manage their employer-based private health insurance plans. The magnitude of such additional savings are more difficult to estimate, but they might be on the order of double the size of savings from the more efficient administration of the health insurance itself. That is, total savings in 2016 might have been on the order of $600 billion, or three times the $200 billion in savings from more efficient administration of health insurance alone.

And such savings (or rather the lack of it under our current complex and fragmented system) can account for a significant share of the far higher cost of health care in the US than elsewhere. As noted before, health care costs about 18% of GDP in the US, or 50% more than in the second most expensive country where it is just 12%. Had the US been able to save $600 billion in health care expenditures in 2016 by moving to a Medicare-for-All system, US healthcare spending would have been reduced from 18% of GDP to below 15% (more precisely, from 17.9% in 2016 to 14.7%). This, by itself, would have gotten us over halfway to what other countries spend. More should be done, to be sure, but such a reform would be a major step.

So why has it not been done? While the lower costs under a Medicare-for-All system would be attractive to most of us, one needs also to recognize that those higher costs are a windfall to those who are skilled at operating within our complex and fragmented system. That is, there are vested interests who benefit under the current system, and the dollar amounts involved are massive. Private health insurers, and their key staff (CEOs and others), profit handsomely under this system, and it should not be surprising that they lobby aggressively to keep it. Under a Medicare-for-All system, there would be no need (or a greatly reduced need, if some niches remain) for such private health insurance.

This is not to deny that there will be issues in any such transition. Just the paperwork involved to ensure everyone is enrolled properly will be a massive undertaking (although for all those currently enrolled in some health insurance plan, mostly via employer-based plans, the paperwork could presumably be transferred automatically to the new program). Nor can one guarantee that while on average health care consumers will save, that each and every one will. But the same is true in any tax reform, where even if taxes on average are being cut, there are some who end up paying more.

One should also acknowledge that many doctors and hospitals are concerned that in a Medicare-for-All system they will have little choice but to agree to the Medicare-approved rates for their services. However, it is not clear this is much different from the current system for the doctors, where they must either agree to accept the in-network rates negotiated with the private health insurers, or expect few patients. And surveys of doctors on their support for a Medicare-for-All system show a turnaround from earlier opposition to strong support. A survey published in August 2017 found 56% of physicians in support (and 41% opposed), a flip from the results of a similar survey in 2008 (when only 42% were in support, and 58% opposed). A key reason appears to be the costs and difficulties (discussed above) doctors face in dealing with the multiple, fragmented, insurance plans they must contend with now. Even the American Medical Association, a staunch opponent of Medicare when it was approved in the 1960s, and an opponent ever since, may now be changing its views.

Administrative cost shares vary enormously across different health insurance programs, from just 2.4% for government-managed Medicare to 37% for health insurance provided through Workers’ Compensation plans. The figures are shown above in the top table in the post. Some might say that this cannot be – that they are all providing health insurance so why should the differ by so much. But they can and they do, and this annex will discuss why.

Take the case of Workers’ Compensation first. Workers’ Compensation insurance was established by states in the US starting in 1902 (Maryland was the first). Most states passed laws between 1910 and 1920 requiring businesses to arrange for such insurance, and by 1920 all but five states (all in the South) had such coverage (and by 1948 all states had it). And in most (but not all) states, health care benefits are provided through the purchase of privately managed insurance.

But these programs are expensive to administer. Each individual claim must be scrutinized to determine that it was in fact due to a covered workplace injury. This leads to the extremely high (37%) administrative cost share. If the injury is indeed covered, the workers’ compensation insurance arranged by the business will pay for the associated health care costs. But if it is not, the injury will now normally be covered by the individual’s regular health care insurance. The treatment is still needed, and is provided. The issue is only who pays for it.

Hence the time and effort spent to ascertain whether the injury was in fact due to a covered workplace injury is a pure social cost, and would not be needed (at least for the health care treatments) in a Medicare-for-All system. The injuries would still be treated, but funds would not need to be spent to see whether the costs can be shifted from one insurer to a different one. And when each individual claim must be assessed (with many then rejected), the administrative costs for Workers’ Compensation plans can be a high share of what is in the end paid for healthcare treatments.

When workers’ compensation programs were first set up, in the early 20th century, individual health insurance was not common. Such health insurance (set up through employers) only began to be widespread during World War II, when the Roosevelt administration approved favorable tax treatment of such insurance by businesses (who were trying to attract workers, but were subject to general wage and price controls). But workers’ compensation programs continue to exist, despite their high administrative costs. And from the point of view of the private insurer providing the workers’ compensation cover, spending such money to assess liability for some injury makes sense, as (from the private perspective of the individual insurer) they would gain if the health treatment costs can be shifted to a different insurer. But such expenditures do not make sense from the perspective of society as a whole. They are just a cost. And under a Medicare-for-All system the injury would simply be treated, with no need to ascertain if one insurer or a different one was responsible for making the payment. Overall costs would be less, with the same health care treatments provided.

There are similar socially wasteful expenditures in other health insurance programs, which drive up their administrative costs. CHIP (Children’s Health Insurance Program) has a relatively high administrative cost share (17.3% in 2016) in part because it is relatively small ($16.9 billion in expenditures in 2016, which can be compared to the $678.8 billion for Medicare), so it does not enjoy the economies of scale of other programs, but also because eligibility for the program must be assessed for each individual participating. While rules vary by state, children and teens are generally eligible for CHIP coverage up to age 18, for families whose incomes are below some limit, but who are not receiving Medicaid (or in coordination with Medicaid in certain cases). The CHIP insurance for the children and teens is then either free or low-cost, depending on family income.

Confirming that children to be enrolled under CHIP meet the eligibility requirements is costly. Hence it is not surprising that this (along with the lack of the economies of scale that larger programs can take advantage of) leads to the relatively high share for administrative costs. But this eligibility question would not be an issue that would need to be individually assessed in a Medicare-for-All system. It is a socially wasteful expenditure that is required only because the program needs to confirm those enrolled meet the specific eligibility requirements of this narrow program. And a Medicare-for-All system would of course enjoy huge economy of scale advantages.

Medicaid also has to bear the cost of assessing whether eligibility requirements have been met, and certain states are indeed now making those eligibility requirements even more burdensome and complex (in the apparent hope of reducing enrollment). Most recently, the Trump administration in early 2018 issued new rules allowing states to impose work requirements on those enrolled in Medicaid, and several states have now started to impose such restrictions. But such requirements are themselves costly to assess. While enrollment in Medicaid may then fall (leading to the health care costs of those individuals being shifted on to someone else), administrative costs as a share of what is spent will rise. But from the point of view of society as a whole, shifting the cost of health treatment for those individuals who would otherwise be enrolled in Medicare on to someone else does not save on the overall cost of health care. And indeed, if it shifts such treatment from doctor’s offices to treatment in emergency rooms, the cost will go up, and probably by a lot.

This would no longer be an issue in a Medicare-for-All system. There would be no need to waste funds on assessing whether the individual meets the eligibility requirements of some specific health insurance program or another.

Despite such special costs. the overall costs of administration for Medicaid were 10.7% in 2016. This is a bit below the cost for regular private insurance of 11.5%, and probably reflects the significant economies of scale Medicaid is able to benefit from. And while a significant share of the Medicaid administrative costs are incurred by private insurers contracted to manage the Medicaid programs in many of the states ($36 billion of the $60 billion total for administration according to the NHE figures), government itself takes on a significant share of the administration. And the overall administrative cost combined is still less than what private health insurance requires (as a share).

b) The Cost of Administering Private Health Insurance

Which brings us to the question of why private health insurance costs so much to administer, at 11.5% of the total paid for such insurance. Medicare, when administered directly by government, has a cost of just 2.4%. Why does private insurance cost so much more?

First, a note on terminology. Up to this point, as we have discussed various government health insurance plans (such as Medicaid or CHIP), we have not had to distinguish the total cost of the health insurance plans (the total of what is paid out in benefits to health care providers, plus what is paid for administration) from the total paid for the insurance cover. We need to be more precise for private insurance cover. One has the total paid in any period (a year in these figures) in insurance premia by the subscribers, and the total in what is paid by the private insurer in each such period to cover benefits. The NHE has estimates for each of these, and then calculates the difference between the two as the “net cost of health insurance”. We have referred to this as a broad concept of administrative costs, as it includes any profits earned by the insurers as part of their current operations. But private insurers have an additional source of earnings, and that is from revenues on invested capital. Premia are paid upfront and benefits paid out later (in overall probabilistic terms), and an important source of income to insurers comes from what they earn on those funds as they are invested in various asset markets, such as stocks and bonds, real estate, commodities, and so on.

For private insurance we should therefore be clear that what we have so far referred to as the “total cost” of the health insurance is synonymous with the total premia paid (which some sources refer to as “underwriting revenue”). Subtracting the total paid to health care providers under the insurance policies from the total paid in premia will then lead to the broad concept of administrative costs, including profits earned from the current period insurance operations. On top of this, private insurers will generate earnings from investments on their accumulated capital (obtained, in part, from premia being paid in before benefits are paid out). For the figures here we are excluding these latter earnings. Such earnings will be on top of those obtained from their current insurance operations.

There are a number of reasons. First, private health insurance is a tremendously fragmented system, where health plans are mostly organized at the individual firm level. This is costly, and the cost share varies systematically by firm size. Administrative costs (including insurer profits) will typically range between 5 and 15% of the total paid for the insurance in firms with greater than 50 employees, between 15 and 25% in firms with fewer than 50 employees, and (in the period before the Obamacare market exchanges were set up) between 25 and 40% of the total for individuals seeking health insurance (see, for example, this report from the Commonwealth Fund).

These high and rising costs (in inverse direction to firm size) arise as there are significant fixed costs in setting up any such system at some firm, which leads to a high cost-share when there are fewer workers to spread it over. Commissions paid to insurance brokers also play a role, as the use of brokers is typical and especially significant for the small-group market. The Commonwealth Fund report cites figures indicating these commissions can account for 4 to 11% of the total in premia paid for insurance in such markets. And in those cases where the insurers themselves take on the risk (as opposed to simply managing the claims process while the firm itself pays the claims – this is called “self-insurance”, and is typical in large firms with 1,000 employees or more, as it ends up cheaper for such firms), the insurers must then invest significant resources in assessing the risk of the pool of workers covered in order to price the policy appropriately. The costs the insurance company will need to pay out will depend not only on the local cost of health care services (which can vary tremendously across different parts of the country), but also by the industry of the firm (as the health risks of the typical workers employed will vary by industry) and specifics of the firm being covered (such as the average age of the workers employed, the male/female ratio, and other such factors).

There are also high fixed costs of the insurers themselves under their business model. They typically offer dozens of insurance plans, each with different features on what is covered and by how much. And most of the plans are built around networks of care providers (doctors, hospitals, and so on) with whom they have individually negotiated “in-network” prices for subscribers of the particular health insurance plan. These in-network prices can still vary tremendously (even by a factor of ten or more, for those I have been able to check with my own insurer, and all for the same metropolitan area), and are set through some negotiation process. The price eventually agreed to reflects some balance in negotiating strength. If you are a hospital chain that dominates in some metro area, you will be able to negotiate a price close to what you wish to charge as the insurer has to include hospital services. Similarly, if you are an insurance company that dominates in some metro area, then the hospitals have to agree to charge something close to what you are willing to pay, as otherwise they will not have many patients. And individual doctors operating in private practices will generally have very little negotiating power.

But such negotiations (for each and every health care provider, and then for each possible service) are expensive to carry out, regardless of the outcome. And while some argue that such negotiations hold down the cost of health care, it is not at all clear that such is the case. The US, after all and as noted before, has by far the most expensive health care services in the world (close to double the average in OECD countries, as a share of GDP), and yet achieves only mediocre results. Furthermore, the actual volume of health care services provided in the US (as measured, for example, by doctor consultations per capita per year, or hospital beds per 1,000 of population, and so on) has the US at close to the bottom among OECD countries. The problem is not excessive health care services utilized, but rather their high cost in the US. Negotiated in-network pricing has not helped, and quite possibly (due to the resulting fragmentation into non-competing markets) has hurt.

This complex and fragmented system does lead, however, to high rewards to those who are good at operating in it. Hence CEOs (and other senior staff) of insurance companies skilled at this are rewarded handsomely, with such CEOs typically receiving compensation of more than $10 million a year, and in some cases far more. Indeed, as recounted in an earlier blog post, the CEO of UnitedHealth Care personally received total compensation of more than $1.3 billion over his 15-year tenure of 1991 to 2006 (even after the SEC forced him to forfeit stock options worth a further $620 million due to illegalities in how they were priced). Such salaries are reflected in the administrative costs of the health insurance plans offered, and account for a substantial share of it.

Finally, this complex and fragmented market has also led to high profits for the private health insurance companies. If this were due to the exceptional efficiency of certain of the health insurance firms as compared to others, all in a competitive market, then such high profits of such firms might be explained. But there is no indication that health insurance markets operate anywhere close to what economists would call “perfect competition”. The extremely wide variation in prices for the same health care services (often by a factor of ten or more) is a clear sign of markets that are nowhere close to perfectly competitive.

And the amount paid to cover such profits is high. For example, an examination of health insurance markets in New York State found (in data for 2006) that profits from underwriting (i.e. excluding profits from capital invested) accounted for 4.9% of total underwriting revenue (the total premia paid) before taxes, or roughly one-third of the total 14.9% in administrative costs (including underwriting profits). After taxes, it would be roughly one-quarter of the total. Applying that ratio to the 11.5% administrative cost share found in the NHE accounts for the nation as a whole in 2016, the charge to cover profits would be close to 3% points. That, by itself, would be greater than the 2.4% cost share for government-managed Medicare.

c) The Cost of Administering the Portion of Medicare Managed Directly by Government

Why, then, does the portion of Medicare (Parts A and B) managed directly by government cost so little? It is fundamentally because Medicare does not bear many of the costs discussed above for the other insurance plans, and can spread the costs that remain over a far larger enrollment base. Specifically:

1) Medicare enjoys huge economy of scale advantages: The portion of Medicare managed directly by government is huge, at $390.7 billion spent in 2016 ($381.4 billion of which went to health care providers, and only $9.3 billion to administration). And this is for a single plan. Private health insurers instead each manage dozens of plans covering millions of firms (at rates which vary firm to firm, depending on the risk pool).

2) Medicare does not have to make a determination for each individual claim as to whether it will be covered (as Workers’ Compensation plans must), nor whether the individual is eligible (other than whether they are of age 65 or more, and have paid the relevant premia and taxes). That is, Medicare does not need to contend with the complex (and now being made increasingly complex) eligibility requirements for participants in Medicaid, CHIP, and other such programs.

3) Medicare has one set of compensation rates, which doctors and hospitals accept or not. The compensation rates vary by region and other such factors, but they are not individually negotiated each year with each of the possible providers.

4) And Medicare does not have the costs private insurers need to pay to retain the CEOs and other senior staff who are skilled at operating within the fragmented US healthcare system, nor do they pay large amounts for marketing and such. Nor does Medicare pay profits, and profits, as noted above, are high for private health insurers in the US.

It is this “business model” of Medicare which keeps its costs down. It is a relatively simple model (relative to that of private insurers – no health care payment system is simple in an absolute sense), and enjoys great economies of scale. Thus Medicare can keep its costs down, and needs to spend on administration only a fraction of what private health insurers spend.

d) The Conservative Critics of Medicare Costs

There are critics who contend that Medicare costs are not in fact low. These critics have issued analyses through such groups as the Heritage Foundation (conservative, with major funding from the Koch brothers), the Cato Institute (conservative – libertarian), lobby groups with a vested interest, and publications that link back to these analyses. But these arguments are flawed. Indeed, some of the responses to the assertions are so obvious that one must assume that ideology (a view that it is impossible for government to be more efficient) was the primary driver.

These critics make three primary arguments:

1) First, several contend that Medicare does not pay for, nor include in its recorded administrative costs, the costs incurred by Social Security and other government agencies that provide services that are essential to Medicare’s operations. For example, initial enrollment in Medicare at age 65 is handled through the Social Security Administration, and Medicare premia payments (for Parts B and D) are normally collected out of Social Security checks.

However, while it is true that Social Security provides such services to Medicare, it is not true that Medicare does not pay for this. A simple look at the Medicare income and expenses tables in the Medicare Trustees Annual Report will show what those payments are. For example, for fiscal year 2017, Tables V.H1 and V.H.2 (on pages 217 and 218 of the 2018 report) indicate that $980,805,000 was paid to the Social Security Administration under the Medicare HI Trust Fund (“Hospital Insurance”, for Part A) and $1,247,226,000 under the Medicare SMI Trust Fund (“Supplementary Medical Insurance”, for Parts B and D). These are substantial amounts, and they are not hidden.

And the tables similarly show the amounts paid by Medicare (as components in its administrative costs) to other government agencies for services they provide to Medicare. These include payments made to the FBI and the Department of Justice (for fraud and abuse control), to the Office of the Secretary of Health and Human Services (HHS, for oversight) as well as to other HHS offices (such as the Inspector General), to the US Treasury, and to a number of others. They are all shown. The conservative critics who assert Medicare expenses do not include payments for such services simply never looked.

2) Second, the critics argue that while private insurers must raise the capital they need to fund their operations, and that that capital has a cost, the costs of funding Medicare’s “capital” are not counted but rather are hidden away in the overall government budget.

But this reflects a fundamental confusion on the capital requirements of established insurers, whether private or public. Insurers are not banks. Banks raise funds (at a cost) and then lends them out. Insurers take in premia payments from those insured, and at some later time make payments out under the insurance policies for covered costs. On average, the payments they make come later than the payments they receive in premia, and hence they have capital to invest. That capital is invested in stocks and bonds, real estate, commodities, or whatever, they make a return on those investments, and that return is factored into, and can reduce (not raise), the premia they need to charge to cover their overall costs.

Private insurers hence generate earnings from their capital, as it is invested as an asset. It is not a cost. Furthermore, Medicare operates in fundamentally the same way as other insurers. The Medicare Trust Funds (HI and SMI) reflect funds that have been paid in and not yet expended in covered claims or other expenses, and they earn interest on the balances in those trust funds (at the long-term US Treasury bond rate). The accounting is all there to be seen, for those interested, in the Medicare Trustees Annual Report.

3) Probably most importantly, the conservative critics of Medicare assert that it is incorrect to calculate administrative costs as a share of the total costs paid. Rather, they say those costs should be calculated per person enrolled. Since older people have far higher medical costs each year than younger people do (which is certainly true), they argue that the low administrative cost share seen in Medicare (when taken as a share of total costs) is actually a reflection of the high health care costs of the elderly.

But there are two problems with this. First, when elderly people see doctors at a pace of say 10 times a year rather than perhaps once a year when younger, they will be generating 10 times as many bills that need to be recorded and properly paid. Each bill must go through the system, checked for possible fraud, and then paid in the correct amount. That will cost more, indeed one should expect it will cost 10 times as much. And if anything, medical procedures are more complicated for the elderly (as they have more complicated medical conditions), so it should be expected that the costs to process the more complex bills will indeed go up more than in proportion to the amount spent. The conservative critics assert the costs of administering this do not go up with the more frequent billing, but rather are the same, flat, rate per person regardless of how many, how complex, and how costly the medical interventions are that they have in any given year.

Second, one has data. The Medicare Parts C (Medicare Advantage) and D (for drugs) are managed via private health insurers. And this Medicare is for the same elderly population that government-managed Medicare covers. If what the conservative critics assert is correct, then the cost of administering these privately-managed Medicare programs should be similar to the cost of administering the portion of Medicare that government manages directly. But this is not the case. Government-managed Medicare spent only 2.4% on administration in 2016, while privately-managed Medicare spent 12.6%. These are far from the same.

Indeed, the 12.6% administrative cost share for the privately-managed portion of Medicare is similar to, but a bit more than, the 11.5% share seen with regular private health insurance. This is what one would expect, where the somewhat higher cost share might well be because of the greater complexity of the medical interventions required for the elderly population.

The government-managed portion of Medicare has a far low administrative cost share than private health insurance. The conservative critics have not looked at the data.

The reports show exceptionally strong improvements in a range of measures of income and well-being. To start, real median household incomes rose by an estimated 5.2% in 2015. There has never before been such a large jump in real incomes since this series first started being reported in 1967. Perhaps more importantly than the overall gains, the Census Bureau data also show that the gains were widespread across income groups (with the poorest 10% decile in fact seeing the largest gains) as well as across race and ethnic groups. It was not only the rich who saw an improvement.

I should hasten to add that these results are from just one year, and that they follow far less satisfactory results over the last several years. Real household incomes plummeted in the 2008 downturn in the last year of the Bush administration, and were flat or fell further in most years since. It should also be recognized that the Census Bureau figures are based on household surveys, and thus that there will be statistical noise (as the Census Bureau emphasizes). It remains to be seen whether the positive news will continue. But with labor markets now at or close to levels generally considered to be full employment, and with real wages now rising, it is likely there has been an improvement also in 2016. But we will only know a year from now what the survey results will be.

The Health Insurance Coverage report found that health insurance coverage also improved significantly in 2015, as it had also in 2014 but importantly not in the years before. The big change in 2014 was of course the coming into effect of the Affordable Care Act (ACA, or ObamaCare) reforms, with the introduction of the market exchanges on which the previously uninsured could purchase insurance at a reasonable price, as well as the expansion of Medicaid coverage in a number of states (but not all). There are now over 20 million more Americans who have health insurance coverage than had it in 2013, before ObamaCare went into effect.

Not surprisingly, the reports received a good deal of news coverage. It was the lead front page article of the Washington Post the next day, for example. Not surprisingly also, the White House released a summary of some of the key, highly positive, findings. But while the news reports focussed on the strong income gains, and many also noted the health insurance gains, I have not seen a chart such as that above which shows the gains in historical context, and with the Medicaid expansion states and non-expansion states shown separately. This post will discuss that chart and what is going on behind it.

B. The Gains in Health Insurance Coverage Under ObamaCare

The chart above shows the percentage share of the population without health insurance coverage in each year from 2008 to 2015, with this shown separately for those states where Medicaid was permitted to expand (27 states plus Washington, DC, with the status taken as of January 1, 2015) and for those states that did not allow Medicaid to expand (23 states). The figures were calculated from the underlying data tables (the “HIC” series) used in the Census Bureau Health Insurance Coverage report. The data series used here comes from the American Community Survey (ACS), which has an extremely large sample size which permits a meaningful state by state breakdown. It asks whether the individual was uninsured at the time of the interview.

The Health Insurance Coverage report also presents figures at the national level obtained from a different survey called the Current Population Survey – Annual Social and Economic Supplement (CPS ASEC), which is undertaken each Spring. This survey has a smaller sample size than the ACS, which is fine for national level estimates but which does not suffice for state by state breakdowns (as one needs when looking at Medicaid coverage by state). It also asks the somewhat different question of whether the individual had health insurance cover for the entire previous year, rather than on the date of the interview.

The share of the US population without health insurance coverage fell sharply in 2014 and again in 2015. Using figures from the ACS, it had fluctuated modestly in the period from 2008 through 2013, rising from 14.6% of the population in 2008 to 15.5% as unemployment hit its peak in 2010, and then recovering slowly to 14.5% by 2013. It then dropped sharply to 11.7% in 2014 and to 9.4% in 2015. Critics of ObamaCare asserted at the start that the reforms did not and would not lead to more Americans being covered by health insurance. That was certainly not the case. By 2015, there were 20.7 million more Americans with health insurance cover than had it in 2013. This is far from minor, and can make an immense difference in a family’s life.

The CPS ASEC figures also show a sharp drop in the share of the population without health insurance, with these figures quoted in many of the news reports one might see. With its differing definition of who is not covered (for the entire year, rather than on the date of the interview as in the ACS), the shares are somewhat lower, at 9.1% in 2015. It fell from a 13.3% share in 2013 and a 10.4% share in 2014 in these estimates of the share of the population who did not have health insurance over the entire year.

By whichever measure, health insurance cover expanded sharply once the ObamaCare reforms entered into effect. By the ACS measure, the share of the population without health insurance fell from 14.5% of the population in 2013 to 9.4% two years later, or by 5.1% points. It can be expected to fall further, although not to zero. Certain groups in the population (including certain immigrant groups) are not eligible for purchasing insurance through the ObamaCare market exchanges, and thus the non-insured rate will never go to zero. While the floor is not certain, many analysts set the figure at perhaps 4 or 5% of the population. If so, then the improvement seen so far is approximately half of what might ultimately be achievable, provided politically imposed roadblocks are all removed.

C. Medicaid Expansion

The chart also shows the shares of the population without health insurance separately for the states that expanded Medicaid coverage (supported by the ACA and an integral part of it) and those that did not. The system as designed under the ACA has that the working poor and lower income classes would obtain health insurance under Medicaid, with eligibility expanded from those with income up to generally 100% of the federal poverty line previously, to 133% from 2014 onwards. Those with incomes higher than this would purchase insurance from the market exchanges, with a subsidy that phases out as incomes grow and is phased out entirely at 400% of the federal poverty line. Thus the entire population, no matter how poor, would be able to obtain health insurance.

However, the Supreme Court decided that Medicaid expansion could not be made obligatory on the states even if the federal government is paying for it (as it is here). Rather, the states could choose whether or not to allow Medicaid to expand cover to include those making up to 133% of the federal poverty line. It would be financially foolish for the states not to, as the federal government would cover 100% of the cost of the expanded coverage in the first several years, with this then phasing down to 90% of the additional cost from 2020 onwards. But even with the states covering 10% of the cost from 2020, a net gain can be expected for the state budget due to the increased incomes of hospitals, doctors, nurses, and other health car suppliers who would now be providing care to the poor when they need it (and be compensated for it), and the state tax revenues that would be generated by such higher incomes. The states would also save by being able to reduce state payments made to cover a portion of the costs incurred by hospitals to provide health services to patients who were not able to pay for their treatments, due to a lack of health insurance.

Despite this, 23 states (as of January 2015) decided that the low income earners in their states would not be allowed to receive health insurance cover from Medicaid. Note that these families must indeed be working to be able to have an income of 100% of the federal poverty line (of $24,300 in 2016 for a household of four). Assuming one wage earner, working 40 hours a week for 52 weeks a year (no vacations), they would need to earn a wage of $11.68 per hour to earn this much, or well above the minimum wage of $7.25 per hour. More likely there would be two income earners in such a household, each earning a wage rate of closer to the minimum wage, but likely not able to obtain full time employment of 40 hours a week for 52 weeks a year. These households are not slackers, but rather are working hard to get by.

Yet these states are refusing to allow such households to obtain health insurance cover from Medicaid, despite a net financial benefit to their state budgets. And since the Affordable Care Act was structured that such families would obtain health insurance coverage from Medicaid, and not purchased (with a partial subsidy assistance) through the health insurance market exchanges, they are now left with nothing. These states have deliberately created a gap where their low income workers are effectively denied access to health insurance.

The reason these states have done this is of course political. The 23 states (as of January 1, 2015) that had not permitted Medicaid to expand were states with Republican governors or Republican legislatures (or mostly both) that refused to allow Medicaid in their states to serve such families. And as noted above, this was done even at financial cost to themselves. Nebulous arguments were given that while the federal government would be paying for most or all of the costs in the near term, the federal government might reverse this later, due perhaps to budget pressures. But there is no reason why such a reversal should be expected, nor why, if there were indeed such budget pressures, it would apply to Medicaid but not to other federally funded programs that those states are taking advantage of. Furthermore, if this did indeed happen at some uncertain point in the future, the Medicaid programs in the state could be cut then, rather than now in anticipation that this might somehow happen at some unknown point in the unknown future.

As shown in the chart at the top of this post, the share of the population without health insurance cover fell to just 7.2% in 2015 in the 27 states (plus Washington, DC) that allowed Medicaid to expand, far below the 12.3% in those states that blocked that expansion. Compared to 2013, before the ObamaCare reforms went into effect, this was a reduction of 5.6% points in the states that allowed Medicaid to expand, versus a reduction of 4.5% points in the states where the expansion was blocked. Put another way, the share of the population without health insurance fell by 43% in the states that allowed Medicaid to expand, versus a fall of just 27% in the states that blocked it.

Furthermore, the far better improvement in the Medicaid expansion states was from a lower starting point in 2013 (of 12.8% of their population without health insurance, versus 16.7% in the states blocking Medicaid expansion). One should expect that improvement becomes more difficult as one comes closer to the achievable ceiling in coverage.

But the chart also serves to show that the states blocking Medicaid expansion historically had a high share of their populations without health insurance. These were conservative states, often relatively poor, with political establishments that did not exhibit great concern over the fact that a high share of their population could not get health insurance. But not all were poor. Indeed, the state with the absolute worst share of any state was oil-rich Texas, with 22.1% of its population without health insurance in 2013, and still 17.1% without it in 2015 (where both figures were the highest in the US in the respective years). Out of 50 states (plus Washington, DC), Texas was the worst. This was a political choice, not an economic one.

It should also be noted that the reduction in the shares of uninsured in those states that allowed Medicaid to expand was not due solely to the increased number of Medicaid enrollees. Between 2013 and 2015, those states saw 12.2 million of their citizens obtain health insurance cover. Of these, 7.6 million came from increased enrollment under Medicaid, while 4.5 million came from other health insurance cover (including through the ObamaCare market exchanges). And as noted above, they were starting from a point where a relatively high share of their citizens (compared to the states where Medicaid expansion was blocked) enjoyed some form of health insurance cover previously.

D. The States That Allowed Medicaid to Expand Also Had Lower Premiums on ObamaCare Health Insurance Plans than on Company-Based Plans

There is also an interesting finding that the states that allowed Medicaid to expand not only saw greater improvements in the shares of their citizens who enjoyed health insurance cover, but also saw insurance premiums on their ObamaCare exchanges (as of 2016) which were lower than comparable company-sponsored plans in those states.

A recent study by the Urban Institute (a non-profit think tank) found that for similar health insurance cover, the full prices (before subsidies) of health insurance purchased through the ObamaCare exchanges were 10% lower on average (at the national level), than the full prices of similar health insurance plans provided through employers. The calculations were made state by state, as costs varied by state, and varied widely. But on average, the ObamaCare plans cost 10% less.

This may be come as a surprise to many. The issue is that most employees do not know what the full cost of their company-sponsored health insurance plans in fact is. The full cost includes not only what they pay directly, but also what they pay indirectly through the employer (which they typically never see) as part of their overall labor compensation package. But it is part of their wages and a cost that must be covered.

The 10% lower cost is an average at the national level. But the Urban Institute figures are calculated at the state level, and one can calculate from this how they vary between those states that expanded their Medicaid coverage and those states that blocked it. The results are interesting. The simple unweighted averages (I did not have the underlying data necessary to calculate a weighted average properly) were:

Health Insurance Plan Costs: ObamaCare Exchanges vs. Company Based

Unweighted averages

All States

-8%

Medicaid Expanded

-15%

Medicaid Not Expanded

0%

The unweight average lower cost of the ObamaCare plans was 8% nationally. This is different from the 10% figure the Urban Institute cited because the lower costs were especially large in some of the larger states, such as New York, Illinois, Pennsylvania, Michigan, and Ohio (all of which had lower costs of 18% or more). In the unweighted averages, these larger states are weighted the same as smaller states.

But what is especially interesting is that the (unweighted) average lower cost of the ObamaCare plans compared to company based plans was 15% in the states that approved Medicaid expansion but was no different on average in the states that blocked Medicaid expansion.

Why would this be? It was probably not due to the Medicaid expansion itself. One would expect Medicaid expansion would lead to lower health insurance costs for those obtaining health insurance. The reason is that hospitals and other health service providers will have lower costs due to less uncompensated care of patients without health insurance coverage (as more would have Medicaid coverage), and one can expect that these lower costs would then be reflected in lower health insurance costs for those who do pay. However, this should affect health insurance costs of policies purchased through the ObamaCare exchanges and company-based policies similarly, and hence would not likely affect the ratio in cost between the two.

However, the Medicaid expansion states were also the ones that encouraged competitive ObamaCare market exchanges to be established. They did not seek to block these markets or keep them from functioning well. They encouraged competition rather than did whatever they could to hinder it.

It was likely due to this greater degree of competition in those states that supported, rather than hindered, the ObamaCare exchanges that explains the lower costs in those states. This is also consistent with the fact noted above that many of the larger states saw especially low costs (relative to company-based plans) than were observed among the relatively smaller states. The larger states will in general see greater competition, and competition drives down prices.

E. ObamaCare Issues Remain

One can no longer dispute that ObamaCare has succeeded in its primary goal of making it possible for a higher share of the population to obtain the security of health insurance coverage. But this certainly does not mean there are no issues with ObamaCare.

Republicans openly acknowledge that they continue to do whatever they can to block the expansion of access to health insurance under ObamaCare. And these efforts to hinder ObamaCare have achieved some success. As noted above, states that blocked Medicaid expansion have seen less of a reduction in their uninsured populations than was achieved in the states that allowed that expansion. But the efforts to block access to ObamaCare went beyond blocking Medicaid. Most of these states also decided not to implement directly the ObamaCare market exchanges in their states. The Affordable Care Act envisioned that to best allow local control and adaptation to a state’s particular circumstances, state level authorities would be allowed and indeed encouraged to establish such exchanges. Fortunately, the law also included a back-up provision that should a state choose not to establish such an exchange, the federal government could do it to allow the citizens of that state access to an affordable health insurance plan. This was not without difficulties; recall the initial failure of the federal level computer systems when enrollment opened in October 2013 and the system was overwhelmed.

More recently, several of the larger health insurers have decided to withdraw from some of the markets in which they had previously offered health insurance plans on the ObamaCare market exchanges. Most recently, Aetna announced in August that it would withdraw in 2017 from 11 of the 15 states where it had been offering such plans. This followed earlier announcements by UnitedHealth and Humana that they also would be scaling back offerings significantly. This will reduce competition among the insurers in a number of markets around the country, limiting the options enrollees in those markets will have. Indeed, in some counties around the country there will be only one insurer offering coverage through the exchanges, and (unless something is now done) one county in Arizona where there will be no such insurer offering coverage through the exchanges.

The issues could certainly be addressed, if there is the will. All major new social programs, including Medicare and Social Security were fine-tuned through new legislation following their launch to address issues that developed. And this was done on a bipartisan basis. The problem now is that the Republican Party, for political reasons, is doing what it can to block any such adjustments, with the openly stated aim of trying to destroy ObamaCare.

It is still to be seen whether these efforts will succeed. If they do, the US will revert to its previous system, with millions of Americans denied access to health insurance and with sharply rising health care costs that outpaced general inflation for decades.

The US Census Bureau released on September 16 its 2014 report on “Health Insurance Coverage in the United States”. It provides the best estimate available on the share of the US population that is covered by health insurance, drawing on figures from both its Current Population Survey and its American Community Survey. The graph above was calculated from the underlying data used in the report (released by the Census Bureau along with it).

The new figures confirm that Obamacare has succeeded in sharply reducing the number of Americans who must suffer from lack of health insurance. The results are consistent with those released earlier by other organizations, including from the commercial polling firm Gallup and from the non-profit Health Policy Center of the Urban Institute. But the Census Bureau results are derived from larger and more comprehensive surveys than a commercial outfit such as Gallup or a nonprofit such as the Urban Institute can mount.

Gallup, the Urban Institute, and now the Census Bureau, have all found that health insurance coverage improved sharply in 2014, the first year in which the health insurance exchanges set up under Obamacare came into operation. Also important was the expansion from the start of 2014 of Medicaid coverage in 26 of the 51 states plus Washington, DC. The expansion, an integral part of the Obamacare reforms, raised eligibility from what had previously generally been 100% of the poverty line (there was some variation across states), to now include also the working close-to-poor who earn between 100% and 138% of the poverty line. Those earning more than 138% of the poverty line are eligible for federal subsidies (phased out with rising income) to purchase privately provided health insurance on the Obamacare market exchanges.

The improvement in health insurance coverage in 2014 (the decrease in the share with no insurance) is clear from these multiple sources. And it should not be a surprise: The primary purpose of Affordable Care Act (aka Obamacare) was precisely to make affordable health insurance available to all. Yet prominent political figures opposed to the act (such as the Republican Speaker of the House John Boehner, and Florida Senator Marco Rubio, now a candidate seeking the Republican presidential nomination) claimed that the Affordable Care Act had actually increased the net number of uninsured. It was clear at the time that they did not understand some basics of insurance enrollment, and it is absolutely clear now that they were dramatically wrong in their assessments. But I am not aware that any of these political critics have had the courage to admit that they had in fact been wrong.

There are some technical issues that arise in the Census Bureau numbers that should be understood, and these will be discussed below. But the basic numbers are clear. Between 2013, before the Obamacare exchanges were in operation, and 2014, there was a sharp reduction in the share of the American population who had no health insurance cover.

This blog post will first review the basic results on improved health insurance cover with the start of the Obamacare reforms, and will then discuss some of the technical issues behind the numbers.

B) The Reduction in the Number of Americans Without Health Insurance Following the Start of the Obamacare Reforms

The graph at the top of this post shows the Census Bureau numbers, as percentage shares of the population with no health insurance over the period 1999 to 2014. Unfortunately (and as will be discussed further below), the Census Bureau changed its methodology in 2013, so the 2013 and 2014 figures are not directly comparable with the figures for 1999 to 2012. However, the 2013 and 2014 figures are directly comparable to each other, and show the sharp drop in the share of the population without health insurance in 2014 (the first year of the Obamacare market exchanges) compared to what it was before.

The share of the population without health insurance cover at any point in the calendar year fell from 13.3% in 2013 to 10.4% in 2014. In terms of absolute numbers, the number of Americans without health insurance cover fell from 41.8 million in 2013 to 33.0 million in 2014, a reduction of 8.8 million or 21%. The number of Americans with health insurance cover rose by 11.6 million, with this number different from the reduction in the number with no insurance cover (the 8.8 million) because the overall US population is growing. Furthermore, this was not (as some politicians have charged) solely a result of the Medicaid expansion. While the Medicaid expansion was important, with an increase of 6.7 million enrolled in Medicaid (both under its prior program conditions, as well as under the expanded eligibility rules), the total number of Americans with some form of health insurance rose by well more than this.

The chart also shows the shares without health insurance separately for the group of states that as of January 1, 2014, had chosen not to take the federal money to expand Medicaid coverage to include the working close-to-poor (those earning between 100% and 138% of the poverty line). Twenty-six states (all with a Republican governor or state legislature or usually both) decided not to expand Medicaid coverage to allow this segment of the population to obtain health insurance, despite the fact the additional costs would be covered 100% by the federal government for the first several years, with this then phased down to a still high 90% ultimately. Even at the 90% federal cost share, the net cost to the state would not simply be small, but in fact negative. Due to the higher state tax revenues that would be gained from what Medicaid would be paying hospitals, doctors, and nurses to provide health services to these close-to-poor, plus the lower state subsidies that would be needed at hospitals to cover a share of the cost of emergency room care that the uninsured must use when they have no alternative, the states would in fact come out ahead financially by accepting the Medicaid expansion. Yet for purely political reasons, the Republican governors and legislators in these states refused to permit this Medicaid expansion, leaving this segment of the population with no health insurance cover.

It is also interesting to note from the chart at the top of this post that actions in this group of states to limit (or at least not facilitate access to) health insurance cover appear to have begun much earlier. The shares of the population without access to any health insurance cover in those 26 states which as of January 1, 2014, had chosen not to expand Medicaid coverage, are shown as the red line in the chart. The shares in the 25 states plus Washington, DC, that did decide to expand Medicaid coverage are shown in the blue line. In 1999 (the first year with comparable data in this series) and 2000, there was no such a discrepancy in health insurance cover between these two groups of states. Indeed, in 1999 a slightly smaller share of the population had no insurance cover in the red states than in the blue states. In 2000 the shares were almost identical.

But this then changed. Starting in 2001, a consistent gap started to open up in the shares between the two groups of states, with fewer covered by insurance in the red states than in the blue. The overall national trend for the share of those with no insurance cover was also upwards. Why the gap between the two groups of states started to open up in 2001 and remain to this day is not fully clear, but it may reflect the trend to more conservative politics that started at that point (including the start of the Bush administration in 2001). The refusal to accept the Medicaid expansion (even at a cost to themselves), and other measures aimed at blocking Obamacare or at least make access more difficult (such as refusal to operate market exchanges at the state level), is in keeping with the observed deterioration in access to health cover in these states well prior to Obamacare ever being debated.

C. Some Technical Notes

Estimates of the share of the population with or without health insurance cover come from surveys, and thus have the strengths and weaknesses of any surveys. The accuracy of the results will depend on how well those being surveyed recall and answer correctly what they were asked. The results will often depend on the way the questions are worded, and sometimes even on the sequence in which the questions are asked. The Census Bureau recognizes this, continually tests its questionnaires, and periodically will change the way they ask their questions in a survey in an effort to obtain more accurate results.

Unfortunately, when there is such a change the new survey results will not be strictly and directly comparable with the responses provided in the past. Often the Census Bureau will use various methods to try to link the different data series into one consistent whole, but this is not always done. One way to do this, for example, would be to conduct two parallel surveys when there is to be a change, one following the old method and one following the new, and then with statistical methods to control for sample characteristics, seek to determine by how much the old series would likely need to be adjusted to become consistent with the new.

The Census Bureau did this when methodological changes were made in the series tracking health insurance coverage in 2007 and again in 2011. When the 2007 changes were made, they went back and adjusted figures from 1999 onwards to approximate what they would be following the 2007 approach. And when the 2011 changes were made, they again went back, to 1999 again, to produce a consistent series that eventually covered the period 1999 to 2012.

However, when the changes implemented in 2013 were made, the Census Bureau did not go back to adjust previous figures for consistency with the new approach. I have found no explanation for why they have not, but would guess it might well be linked to budget cuts. But for this reason, one cannot assume that the figures showing a reduced share of the population without health insurance in the 2013 figures compared to those in 2012, are necessarily due to more people enrolling in health insurance in 2013 relative to 2012. Hence the gaps in the lines in the graph as drawn above.

Indeed, other evidence suggests that coverage in 2013 was similar to that in 2012. Specifically, the Gallup numbers previously cited indicate that share of uninsured in 2013 was actually a bit higher than where they were in 2012 (averaging what are quarterly estimates). There was then a sharp fall in 2014 in the Gallup figures following the start of the Obamacare exchanges and the Medicaid expansion, consistent with the Census Bureau numbers.

It is unfortunate the Census Bureau did not try to work out a consistent series of estimates for health insurance coverage for this critical period. But for whatever reason they did not (at least not yet). But what we do know from the Census figures is that the share of the uninsured in the population was trending upwards over the 1999 to 2012 period, and that there was a sharp reduction in the share uninsured in 2014 compared to what it was in 2013. And that is therefore all we could work with in this post.

Another issue is that the state by state figures were determined by the Census Bureau under one survey for the 1999 to 2012 period (the Annual Social and Economic Supplement to its Current Population Survey, or CPS-ASEC), but then a different survey for 2013 and 2014 (the American Community Survey, or ACS). Both are large surveys, asking questions on a variety of issues. But they ask somewhat different questions on the issue of health insurance coverage. Specifically, the CPS-ASEC, which is undertaken between February and April of each year, asks the respondents whether they had had health insurance coverage at any point in the previous calendar year (separately for each household member). The ACS survey, in contrast, is undertaken on a rolling basis throughout the year, and the question asked in that survey is whether each household member had health insurance cover at the time they were being interviewed.

These are of course different questions. And by simple arithmetic, it should be clear that the responses to whether they had insurance at any point in the year will, for the sample as a whole, always be a higher figure than the share in response to the question of whether they have health insurance at the time of the interview. Someone might not have health insurance at the time of the interview, but could have had it earlier in the year (or will obtain it later in the year). The shares uninsured will be the mirror images of this.

The national figures for 2013 and 2014 were:

CPS-ASEC

ACS

No insurance at any

time in the calendar year

No insurance at the

time of the interview

2013

13.3%

14.5%

2014

10.4%

11.7%

The figures in the graph at the top of this post are based on the estimates of coverage at any point in the calendar year. There was, however, a problem in determining on a consistent basis the underlying state figures, from which one could compute the shares for the states that had expanded Medicaid coverage and for those who had not. The figures at the state level that the Census Bureau made available on its web site for the 1999 to 2012 period were from the CPS-ASEC series. However, for some unexplained reason, but as part of the changes introduced with the new 2013 numbers, the state level figures for 2013 and 2014 were only made available under the ACS series. I do not know why they did this, as it introduces another element of inconsistency when making comparisons across time.

Since the bulk of the state level series, for 1999 through to 2012, were published under the CPS-ASEC series, I used those as published. But for 2013 and 2014, I determined the state totals for the Medicaid expansion and Medicaid non-expansion groups based on the ACS numbers (as they were the only ones available), and then rescaled the figures to fit the published national totals (working in terms of the underlying numbers, and then computing the shares). The figures should be very close to what would have been worked out directly from the CPS-ASEC figures if they had been made available at the state level. One would expect the ratio of the figures of those without health insurance under the two different definitions (throughout the year or at the time of the interview) would not differ significantly between the two groups of states (those with and without the Medicaid expansion).

D) Conclusion

Technical issues exist with any data set, and it is important to recognize what limitations such issues place on what one can infer from the figures. Unfortunately, the Census Bureau numbers as published do not permit us to compare directly the 2013 and 2014 results to those of 1999 to 2012. However, the 2013 and 2014 results are directly comparable to each other, and they clearly show that there has been a major improvement in health insurance coverage in 2014 after the Obamacare exchanges and Medicaid expansion came into effect.

The distribution of the gains from economic growth has gotten horribly skewed since around 1980, as the graph above shows (using a log scale so that distances on the vertical scale are equal relative changes). Average real incomes of the bottom 90% of households have fallen by 5% in real terms since 1980, while the real incomes of the top 0.01% have grown by 325%. This is astounding. Something has changed for the far worse in recent decades. The real incomes of these groups grew at roughly similar rates in the post-World War II decades leading up to 1980, but then diverged sharply.

An earlier post on this blog looked at the proximate factors which took substantial growth in GDP per capita (which grew at about the same pace after 1980 as it had before) down to median wages that simply stagnated. As discussed in that post, this was principally due to a shift in distribution from labor to capital, and a shift within labor from the lower paid to the higher paid. (Demographic effects, principally the increased participation of women in the labor force, as well as increases in the prices of items such as medical care relative to the prices of other goods, were also both important during this period. However, both have now become neutral, and are not factors leading to the continuing stagnation in recent years of median wages.)

The purpose of this blog post is to look at concrete policy measures that can be taken to address the problem. The issue is not slow growth: As noted above, per capita growth in GDP since 1980 has been similar to what it was before. The problem, rather, is the distribution of the gains from that growth, which has become terribly skewed.

Discussion of this is also timely, as a consensus appears to be forming among political leaders in both major parties that something needs to be done about the stagnant incomes of the poor and middle classes. Several of the candidates seeking the Republican presidential nomination have said they wish to make this a primary issue of the 2016 campaign. This is good. If they are serious, then they would support measures such as those laid out below. I doubt they will, as they were strenuously opposed in the past to many of them, and indeed championed the changes in policy from the Reagan period onwards which are, at a minimum, associated in time with the deterioration in distribution seen in the chart above. But one can hope.

This is a long blog post, as it discusses a long list of measures that could be taken to address the predicament of the poor and middle classes. Many (although not all) of these policies have been reviewed in previous posts on this blog. Thus the discussion here will in such cases be kept individually brief, with the reader encouraged to follow the links to the earlier blog posts for more substantive discussion of the points being made. And the reader with limited time may wish to scan through the section headings, and focus on those topics of most interest.

II. A Policy Program

A. Labor Market

We start with the labor market, as it is fundamental.

1) Raise the minimum wage: The minimum wage is now less in real terms than what it was in 1950, during the presidency of Harry Truman. This is amazing. Or perhaps what is amazing is the argument made by some that raising it would price workers out of their jobs. Real GDP per capita is now 3.75 times what it was then, and labor productivity has grown to 3.5 times what it was then. But the minimum wage is now less in real terms than what it was then. The minimum wage in 1950 was not too high to price low paid workers out of the market, and labor productivity is three and a half times higher now.

Obama has called for the minimum wage to rise to $10.10 per hour from its current $7.25 per hour (with this then indexed to the rate of inflation). This would bring the minimum wage back only to where it was in the 1960s, a half century ago. There is no evidence that such a rise will hurt low wage workers, and it would still leave a full time worker (at 40 hours a week, and with no vacation time, so 52 weeks per year times 40 hours per week = 2,080 hours per year) at such a minimum wage (2,080 x $10.10 = $21,008 per year) earning well less than what is needed to bring a family of four up to the poverty line ($24,250 per year for a family of four in 2015). This is the minimum that should be done. Indeed, it should be more.

2) Ensure predictable work hours: Many workers, particularly in sectors such as retail and food service (whether fast food or traditional restaurants), are increasingly being required to accept “flexible” work hours, where their employer tells them only a short time ahead what days to come in, at what time to report, and for how many hours. They might be told a few days before, or only the day before, or sometimes only on the day of possible work, whether they will be needed and should report to work. This is sometimes called “just-in-time” scheduling (a term taken from just-in-time inventory management) or “on-call” scheduling, and managers are rewarded for what is seen as “optimizing” their use of labor.

But it plays havoc with the life of many workers. They cannot take a second job in the evening to help make ends meet, if they do not know whether their primary job may sometimes require that they come in on short notice to work an evening shift. Students cannot enroll in college classes in order to finish a degree if they do not know whether they might be called in during class time. Parents and especially single mothers can have great difficulty in arranging for child care when their work schedules are unpredictable. And an unpredictable number of weekly work hours, of perhaps 30 hours one week and 20 hours the next, makes budgeting impossible.

Recent developments in computer and communications technology have made on-call scheduling possible and increasingly common. Establishments such as Starbucks can receive at some central office real-time information on coffee sales (from the cash registers, via an Internet connection), and together with other factors (weather forecasts; whether a convention is in town) can run sophisticated software algorithms predicting how many workers will be needed, exactly when, and which ones should be called in.

Starbucks can possibly be shamed into improving it working conditions, as it sells high-end coffee to those with significant disposable income. And if the problem were solely with Starbucks and a few similar firms, a shaming approach might possibly be effective. However, while Starbucks may have become the symbol, the practice has unfortunately become increasingly widespread. Furthermore, there is competitive pressure across firms to adopt such practices. If Starbucks stops the practice, it may face coffee retailers who continue to “optimize” their use of labor through such practices, who can then take away business by charging less. There is thus pressure on firms to impose the lowest standards they can get away with.

There is no federal law against such labor practices. There may be state laws which might constrain the practices in some way in certain jurisdictions, but they are not widespread. What is needed is a legislated solution which will apply generally, and should be undertaken at the federal level. This has been done before.

Abuses of labor had become common during the “gilded age” of the late 1800s / early 1900s (when income distribution was, not coincidentally, as bad as it is now). Progressive Era and later New Deal reforms addressed some of the more egregious issues. Work place safety and child labor laws were enacted, a minimum wage was established, and a 40 hour work week was set as the standard, where a worker is required to be paid overtime at the rate of “time and a half” (150% of their regular wage) for any hours worked beyond 40 in a week.

The issue of unpredictable work hours could be addressed similarly. All workers would have a normal set of hours, defined individually and a function of their particular job. They would always be paid for this set of normal hours. But it is recognized that firms may have an unexpected need for additional workers at certain times (for example to substitute for a worker who is sick). Workers could take on such additional shifts beyond their regular hours if they so chose, but as a financial inducement for the firm not to rely on such job calls, the firm would be required to pay 150% of normal wages for such time (as for overtime work).

This would lead firms to assess better when they need workers and when not, and build this into the standard work schedules. Firms have little incentive to do this now, since the cost of unpredictable schedules is shifted onto the workers. Note also that with this system there will not be an incentive to further split up jobs, as all workers will be assigned an individualized normal schedule. The firms will gain no flexibility by splitting a 30 hour a week job into one of 20 hours and one of 10 hours. They will still need to determine when workers are expected to be needed, in order to assign hours accordingly. And to the extent they do not do this carefully, they will be penalized as they will then need to pay 150% of the wage when a worker needs to be brought in to cover those extra hours.

Predictability in hours is extremely important to low wage workers. Indeed, it is quite possibly more important than raising the minimum wage. It will shift some of the costs of unpredictability back onto the firm, where it had been until modern computer and communications technology (and lax labor laws that did not foresee this) allowed the firms to shift onto workers the cost of unpredictability. Firms did this to raise profits, and business profits did indeed then rise while wage earnings stagnated. This is precisely the issue that needs to be corrected.

3) Manage policies to return the economy rapidly back to full employment when there are economic downturns: While it would be ideal always to keep the economy at or close to full employment, economic downturns happen, most recently in 2008 in the last year of the Bush administration. But when they do, the priority should be to return the economy to full employment as rapidly as possible. Everyone can of course agree on this. Differences arise, however, on how to do it.

Monetary policy should be used to the extent possible, but there is a limit to how much it can do since interest rates cannot go below zero. And they have been at essentially zero since late 2008, following the Lehman Brothers collapse. The Fed can also try to reduce long term rates (such as through quantitative easing), and while its policy here has had some beneficial effect, it is also limited.

Monetary policy in a downturn such as that just experienced must therefore be supported also by expansionary fiscal policy. Additional government spending is the most effective way to expand demand, as it does this directly. Tax cuts can also help, but are less effective since a significant share of the reduction in taxes may be partly saved by households (and likely will be largely saved by higher income households). There will thus be less stimulative effect per dollar from tax cuts than from direct spending.

Republicans have argued that to return the economy to full employment, one should instead reduce regulations. But this makes no sense. Regulations in the middle of a downturn are not far different from what they were before the downturn began, so how can they be blamed for the unemployment, and how would reducing them lead to less unemployment? And if some regulations are wrong, one should change them, whether the economy has high unemployment or low unemployment. Regulations do not serve as a macro policy to reduce unemployment, but rather serve a micro purpose to ensure the economy functions efficiently.

A slack labor market will have a direct effect on income inequality. When there is available labor that is unemployed, a laborer will have little leverage to negotiate for higher wages. And unemployment has been higher, on average, in the three decades following 1980 than in the three decades before 1980. A simple regression analysis suggests that if the average rate of unemployment after 1980 had simply matched what it had been before 1980, then the real incomes of the bottom 20% of households would not only have grown at a rate similar to how fast they had grown before, but also at a rate similar to that of the top 20% in the period after 1980. That is, there would have been continued growth in the real incomes of the bottom 20% after 1980, instead of stagnation, and no increase in inequality relative to the top 20%. Keeping the economy at close to full employment is critical to the poor and middle classes.

B. Fiscal Policy

Fiscal policy is therefore an important instrument to keep the economy at full employment, or to return it to full employment from a downturn. What specifically should be done?

1) End the Congressional budgetary “pay-as-you-go” rules when in or recovering from a recession: The Budget Enforcement Act of 1990 required that, as a budgetary rule, any increase in mandatory government spending or reductions in taxes must be “paid for” over the next five years as well as the next ten years by offsetting spending cuts or tax increases, so as to be budget neutral over these periods. While the rules have been modified over the years, were not in place for a period during the Bush II administration, and were not always abided by (such as for the large tax cuts at the start of the Bush administration), they have acted in recent years to limit the government spending that was needed to recover from the downturn.

Over the course of a full business cycle, covering the full period over when the economy is at or close to full employment and when it is not, a limit on the size of the government deficit is warranted. But by setting such a limit to apply identically and continuously both in a downturn and when the economy is booming, one limits the government expenditures that may be needed for a rapid recovery. The rule should be suspended during any period when the economy is in a recession or recovering from one, to be replaced by a rule that applies over the course of the business cycle as a whole and which focusses on the government debt to GDP ratio rather than simply the government deficit.

2) Stop cuts to important safety net programs such as food stamps and unemployment insurance, especially in a downturn: Safety net programs such as food stamps (now called SNAP) and unemployment insurance are critically important to the poor and middle classes, and especially so in a downturn. They provide limited support to households who lost their jobs or other sources of income in the recession, due to no fault of their own. (The 2008 downturn was a consequence of the reckless management of banks and other financial institutions in the US, and the policy decision of the Bush administration officials not to make use of their regulatory powers to limit it. This led to very high bank leverage, a build-up of the housing bubble, and then collapse when the housing bubble burst.)

As unemployment rose and incomes fell, especially of the poor and near poor, many more households became eligible for food stamps and, having lost jobs, for unemployment insurance. Expenditures on these and other safety net programs expanded, as they are designed to do in a downturn. But Congressional Republicans then forced through cuts in the key safety net programs (e.g. unemployment insurance, and food stamps) by limiting eligibility, and have sought much more extensive cuts.

If one wishes to help the poor and near poor, one does not cut programs which help them directly, and especially not when they most need them. These programs are also extremely efficient. The food stamp program (SNAP) spends only 5% of its budget on administrative costs. Few charities are anywhere close to as efficient, but at least some prominent Republicans think otherwise. Former Congresswoman Michele Bachmann, at one point the leading contender for the Republican presidential nomination in 2012, asserted that 70% of food stamp funding went to “bureaucrats”. This was absurdly wrong.

Safety net programs in the US, while efficient for the money spent, are however highly limited in how much they do spend. US income inequality or poverty rates are actually not worse than those seen in other high income OECD economies in terms of wages and other income paid to workers. That is, the US capitalist market economy does not itself produce more unequal outcomes than those of other high income OECD economies. The US is near the average in this across all the OECD countries. But once one takes into account government taxes and transfers, the US turns out to be the very worst, both in terms of inequality (as measured by the Gini coefficient) and in terms of poverty (by the share of the population considered poor). The problem is not that the US tax and transfer programs are not especially progressive: They are in fact more progressive than in most countries. The problem is that they are simply too small to matter.

3) Implement a public infrastructure investment program: American public infrastructure is an embarrassment. Compared to other high income countries, US roads, bridges, mass transit, and other public structures, are clearly inadequate in scale, are in terrible condition due to inadequate maintenance, and constitute what is in effect a growing debt that will need to be repaid in the future when they finally have to be rebuilt (normally at much greater cost than if they had been maintained properly).

Public investment has been cut back especially sharply in recent years, whether measured as a share of GDP or simply in real per capita terms, as a consequence of Congressional cuts in the budget. But while the cuts have been especially sharp since 2010, the problem is long-standing. Amazingly, US non-defense public investment in structures in 2013 was less, in real per capita terms, than what it was in 1960, even though real per capita GDP almost tripled over this period.

It should therefore be no surprise that roads and bridges are in poor condition (with some bridges that have even collapsed), mass transit systems are in poor repair, and all are grossly inadequate to what we need. This impacts especially the middle classes, who have to sit in traffic jams daily just to get to work. Toll roads or tolled lanes built by private concessionaires have become fashionable in recent years to build roads that government is no longer willing to pay for, but they can be expensive. The tolled lanes opened recently in Northern Virginia in the I95/I495 corridor have tolls that, for the entire length, could conceivably reach $40 or more per trip (and double that per day). Rich people can afford this, but most of those with middle class incomes cannot.

Adequate public infrastructure is needed to raise productivity and for the economy to grow. And the recent severe downturn should have been a time for a special effort to expand such investment, putting to work unemployed construction and other workers, in firms that had capacity to produce more than they could sell due to low demand in the downturn. Furthermore, the government could have borrowed long term funds during this period at historically low rates, and even at times at negative real rates. It was insanity not to utilize the unemployed labor and underutilized firms, financed by funds at low or even negative real cost, to build and repair infrastructure that the economy and especially the poor and middle classes desperately need.

But this was not done. It instead will need to be done over the coming years (and at much higher cost, due to the lack of maintenance), when the economy is hopefully at full employment, interest rates have returned to normal levels, and anything extra spent on public infrastructure will need to come out of less being available for other goods and services, including for private investment.

4) Increase public support to higher education: At one time, students could pay for the total costs of attending a state university, including room and board, through work at just the minimum wage during summers and part time during the academic terms. This is no longer the case. In part this is due to the fall in the minimum wage in real terms from where it had been in the 1960s. But it was also a consequence of the rising cost of university education (a result of Baumol’s cost disease) coupled with sharp cutbacks in the share of these costs covered by state support to their colleges and universities, shifting more of the cost onto students and their families.

This reduction in state support to their colleges and universities needs to be reversed, or soon state schools will in effect no longer exist. They will have become essentially private schools catering to those who can afford them. And while federal programs exist to help students (most importantly the Pell Grant program, which provides grants of up to $5,775 per year, in academic year 2015/16), they are limited and family income based. The maximum Pell Grant goes only to the poorest households.

There are different ways to assist students from poor and middle class households to continue their schooling beyond high school. President Obama, in this year’s State of the Union address, proposed for example that federal support be provided so that community colleges would stop charging tuition for students in good standing. One would in essence be extending the availability of public schooling from 12 years now to 14 years. The budget cost would be relatively modest at just $6 billion per year. Others have suggested, constructively, that using such funds to expand the Pell Grant program would achieve the same aim, while assisting also those low income and middle class students who would do better by enrolling in a four-year college.

The response of the Republicans in Congress has, however, been in the opposite direction. While rejecting Obama’s proposal for community colleges, the recent proposal from the House Budget Committee would instead freeze the maximum Pell Grant at $5,775 for at least the next ten years, thus leading to its erosion in real terms as prices rise (much as the minimum wage has eroded over time due to inflation).

C. Tax Policy

Tax policy has a direct impact on income distribution. But while most still accept the principle that taxes should be progressive (the principle that the rich should pay taxes at a higher rate than the poor), the tax system the US in fact has is regressive in many of its aspects.

1) Stop the preferential tax treatment of income from wealth: The wealthy pay a lower rate of taxes on their income from wealth than most of the population pays on their income from labor. In terms of policy options to address inequality, little would be more straightforward than to end the practice of taxing income from wealth at lower rates than income from work. Tax rates on all income groups could then be reduced, with the same total tax revenues collected.

The long-term capital gains tax rate on most assets is only 15% for most earners (there is an additional 3.8% for those households earning more than $250,000 bringing the rate to 18.8%, with this rising by a further 5% points to 23.8% for those earning $464,850 or more in 2015). These rates on income from wealth are well below what is paid by most on income from labor (wages). While the regular income tax rates (on wages) vary formally from 10% in the lowest bracket to 39.6% in the highest, one should add to these the social insurance taxes due. These are often referred to loosely as Social Security taxes, but they include both Social Security at a 12.4% rate (up to a ceiling in 2015 of $118,500), and Medicare taxes at a 2.9% rate (with no ceiling). Note also that while formally the employee pays half of this and the employer pays half, analysts agree that all of the tax really comes out of wages.

Once one includes social insurance taxes on wages, the effective tax rates on income from labor goes from 25.3% for the lowest bracket to 40.3% on those earning between $74,900 and $118,500, after which it drops down to 27.9% as the Social Security ceiling has been hit, and then starts to rise again. The long-term capital gains rate is always below this even for the very richest, and normally far below.

To add further complication, preferential rates of 25% apply to long-term capital gains on certain commercial building assets (“Unrecaptured Section 1250” gains), and 28% apply to collectibles (such as fine art or gold coins) and certain small business stock. These are still well below what most pay in taxes on income from work.

This system not only worsens income inequality, but also creates complications and introduces distortions. Many of those with high income are able to shift the categorization of their incomes from what for others would be wage income, to income which is treated as long-term capital gains. Properly structured stock options, for example, allow CEOs and other senior managers to shift income from what would otherwise be taxed at ordinary income tax rates to the low rates for capital gains. “Carried interest” does the same for fund managers. With many fund managers earning over $100 million in a year, and indeed some earning over $1 billion, this preferential tax treatment of such extremely high earnings is perverse.

The reform would be simple. All forms of income, whether from labor or from wealth, would be taxed at the same progressive rates that rise with total household income. The one issue, which can be easily addressed, is that income from long-term capital gains should be adjusted for inflation, to put the gains all in terms of current year prices. But this can easily be done by scaling up the cost basis based on the change in the general price level between when the asset was bought and when it was sold. The IRS could supply a simple table for this.

2) Reduce marginal effective tax rates on the poor: Conservatives have long argued for cuts in marginal tax rates for the rich, arguing this would lead to faster growth (“supply-side economics”). While there is no evidence that lower tax rates in recent decades have in fact led to faster growth, this was the stated rationale for the big tax cuts under Reagan and then Bush II.

Liberals have noted that if one were really concerned about high marginal tax rates, you would look at the high marginal effective tax rates being paid at the other end of the income scale – by the poor and those of moderate income. Studies have found that these can range as high as 80 or even 100%. The marginal effective tax rates take into account the impact of means-tested programs being phased out as one’s income rises. When extra income is earned, you will pay not only a portion of this in taxes, but you will also lose a portion of benefits that are being provided (such as food stamps) in programs that phase out as income grows. If the extra paid in taxes plus the amount lost in benefits matches additional earnings, the marginal effective tax rate will be 100%.

In reality, the rates being faced by the poor are normally less, although still substantial. The issue is complex since the effective tax paid will depend not only on income, but on such factors as: 1) Family composition (whether married and number and age of children); 2) Where one lives (what state and often what city or county); 3) Particular benefit program qualification criteria (which will vary by program, and will often depend on many factors other than income); and 4) Whether the individual always enrolls in programs they are qualified for, as one may not be aware of certain benefit programs, or find the benefits to be too small to be worthwhile (because of difficulties and complications in enrolling, with these quite possibly deliberate difficulties in some jurisdictions).

The Congressional Budget Office, in a careful study issued in November 2012, concluded that the marginal effective tax rate for citizens with incomes of up to 450% of the federal poverty line averaged about 30% in 2012. And under law as then in effect, this would rise to 32% in 2013 and 35% in 2014. There was a good deal of variation within the average, with a marginal effective tax rate of as much as 95% (for example, for single mothers with one child with an income in the range of about $18,000 to $20,000, which was just above the poverty line for such a household). But rates of 40% or more were not uncommon.

Such rates, even when not at the 80 to 100% extremes cited by Senators Rubio and Lee, are high. Even at just 30% (the average) they are double what those who are far better off pay in long-term capital taxes. While the conservative senators argue that such high marginal rates discourage work effort (there is in fact little evidence that this is the case – when you are poor, you are desperate for whatever you can get), such high marginal rates are in any case unfair. If one wants to help those of low and moderate income, these effective tax rates should be reduced.

There are three ways, and only three ways, to reduce the marginal effective tax rates on the poor. One is to get rid of the benefit programs for the poor altogether. If they receive no food stamps to begin with, one has nothing to lose when incomes rise. But this then penalizes the poor directly.

One could also phase out the programs more slowly, and pay for this by reducing the benefits to the poorest. This is then a transfer from the poorest to the somewhat better off than the poorest. Senators Rubio and Lee proposed this route (without explicitly calling it that) by reducing benefits such as food stamps and providing instead larger child tax credits for all households (including the rich). This would be a transfer from the poorest to those of higher income (including the rich), and especially to those with large families. The poorest would be penalized.

Finally, the third and only remaining option is to phase out the benefit programs more slowly. This reduces the marginal effective tax rate that poor households will face if they are able to obtain jobs paying more than what they earned before. It will not penalize the poorest, but it does of course require that budgets for the programs then rise. But this will be support made available directly to the poor, and in particular to the working poor (as they are the ones facing the high marginal effective tax rates from additional earnings). If one is concerned about poverty and inequality, this is precisely the support that should be provided.

3) Tax inherited wealth the same as any other wealth:Wealth that is inherited enjoys significant tax benefits. The only exception is wealth that is so large that it becomes subject to the estate tax (greater than $10.86 million for a married couple in 2015). But few pay this due to that high ceiling, as well as since one can establish trusts and use other legal mechanisms to avoid the tax. Indeed, in 2013 (the most recent year with available data), estate taxes were due on less than 0.2% of estates; the other 99.8% had no such taxes due. This is down from over 6% of estates in the mid-1970s, due to repeated changes in tax law which narrowed and reduced further and further what would be due.

Any wealth that is passed along within the effective $10.86 million ceiling will never be subject to tax on capital gains made up to the point it was passed along. That is, the cost basis is “stepped-up” to the value upon the date of death. If one had purchased $100,000 of General Electric stock 40 years ago, the stepped-up value now would be roughly $3 million, and no taxes would ever be due on that $2.9 million of gain.

This is not fair. Taxes on such wealth should be treated like taxes on any other wealth, and as argued in item #1 of this section above, all sources of income should be taxed the same (recognizing, importantly, that capital gains should be adjusted for inflation).

Some have argued that this cannot be done for inherited wealth since those inheriting the wealth may not know what the original cost basis was. But this is not a valid excuse. First of all, the two most important categories of wealth that are passed along through estates are homes and other real estate, and stocks and bonds and other such traded financial assets. There are government land records on all real estate transactions, so it is easy (and indeed a matter of public record that anyone can look up) to find the purchase price of a home or other real estate. And purchases of stocks, bonds, and other trade financial assets are done via a brokerage, which will have such records.

Second, if there are any other assets with special value (such as valuable coins or works of art) that will be passed along through an estate, the owner of those assets can include a record of their cost basis as part of the will or trust document that grants the asset to those inheriting the estate.

4) Equal tax benefits for deductions should be provided for all income levels: Under the current tax system, if a rich person in a 40% marginal income tax bracket makes a $100 contribution to some charity, then the government provides a gift to that rich person of $40 through the tax system, so that the net cost will only be $60. If a middle class person in a 20% marginal tax bracket makes a $100 gift to the exact same charity, then the government will pay them back $20, for a net cost of $80. And if a poor person in the 10% bracket makes a $100 gift to that same charity, the net cost to him will be $90.

This is enormously unfair. There is no reason why deductions should be made more valuable to a rich person than to a poor person. And there is an easy way to remedy it. Instead to treating deductions as subtractions from taxable income, one could take some percentage of deductions (say 20%) as a subtraction from taxes that would otherwise be due. The $100 gift to the charity would then cost the rich person, the middle class person, and the poor person, the same $80 for each.

5) Set tax rates progressively, and at the rates needed to ensure a prudent fiscal balance over the course of the business cycle: I have argued above that all forms of income should be taxed similarly. Whether you earn income from working or from wealth, two households with the same total income should pay taxes at the same rates. This is not only for fairness. It would also simplify the system dramatically. And this is not only for the obvious reason that calculations are easier with one set of rates, but also because the current diverse rates interact between themselves in complex ways, which make computing taxes due a headache when there are different rates for different types of income. Perhaps most importantly, it would eliminate the incentive to shift income from one category to another (e.g. from wage income to stock options) where lower taxes are due. That creates distortions and wastes resources that should be used for productive activities.

There remains the question of what the new rates should be. I do not have the data or the detailed tax models which would allow one to work that out, but a few points can be made. One is that the new tax rates would be lower (at any given level of income) than what regular income tax rates (on wage income) are now. This is because the tax rates on income from wealth (such as for capital gains, or inherited wealth) would be unified with the now higher tax rates on income from labor, so the new overall tax rates on regular income can be lower than before to yield the same level of tax revenues. General income tax rates would come down.

Second, one should of course preserve the principle of progressivity in the tax code. Rich people should pay taxes at a higher rate than poor people. As Warren Buffitt argued eloquently in a New York Times column in 2011 (“Stop Coddling the Super-Rich”), there is no economic justification for the rich to pay taxes at lower rates than those with less income. And it is grossly unfair as well. Their secretaries should not pay at higher rates than the rich (fully legally) pay.

Third, one needs to recognize that the purpose of taxes is to raise revenues, and rates should thus be set at the levels required to cover government expenditures over time. As argued above, the budgetary accounts should not be forced to balance each and every year, since fiscal policy is extremely important to move the economy back to full employment in an economic downturn (and fiscal policy is basically all that is available when interest rates are at the zero lower bound, as they have been since late 2008 in the US).

But over the full course of the business cycle, tax rates should be set so that the tax revenues collected suffice to keep the government debt to GDP ratio at a stable and reasonable level. This implies deficits when unemployment is high, and surpluses when the economy is close to full employment. The economy was at full employment in 2006-07 (unsustainably so due to the housing bubble building up in those years) with the unemployment rate below 5% and as low as 4.4%. Unfortunately, due to the Bush II tax cuts, the government’s fiscal deficit in those years was still significant.

Applying these principles, the tax rates needed for this would need to be worked out. This can be done, but I do not myself have access to the data that would be required. In the end, I suspect that regular income tax rates could be reduced substantially from what they are now, with this still sufficient to provide for adequate government expenditures over the course of the business cycle. But the rich would pay more while those of low to moderate income would pay less, and whether this would then be possible politically is of course a different issue.

D. Health Insurance

Access to health insurance is important. A careful statistical analysis published in 2009 found that the likelihood of dying is higher for the uninsured than for the insured, and the lack of universal health insurance (as was then the case in the US) was leading to an estimated 45,000 more Americans dying each year than would be the case if they had health insurance. This is greater than the number of Americans killed in action over the entire period of the Vietnam War.

The ObamaCare reforms have been a big step forward to making it possible for all Americans to obtain access to health care, but it remains under threat. If Republicans are serious about helping the poor and middle classes, they should support the following.

Despite this, Republicans continue to campaign aggressively to terminate ObamaCare, and have supported lawsuits in the courts to try to end this health care access. A case now before the Supreme Court, with findings to be announced this month (June 2015), may declare that the federal government payments made through certain of the ObamaCare exchanges (those not run by the states) to those of low to moderate income, cannot be continued. If the Supreme Court finds in favor of those opposed to such payments, these low and moderate income households will no longer be able to obtain affordable health insurance.

If the Republican presidential candidates are in fact in favor of helping the poor and middle classes, they should call for an end to the continued efforts by their Republican colleagues to terminate ObamaCare. There are ways it could be improved (e.g. by taking more aggressive actions to bring down the cost of medical care to all in the US), but it is working as intended, and indeed better than even its advocates expected.

2) Extend Medicaid in all states in the US: The ObamaCare reforms built on the system of existing health insurance coverage. Medicare would remain the same for those over age 65; employees in firms would normally pay for health insurance coverage through employer based plans; Medicaid would expand from covering (generally) those up to the poverty line to include also those with income up to 133% of the poverty line; and all those remaining without health insurance would be allowed to purchase coverage from private health insurers competing on internet-based health insurance exchanges, where those with incomes of up to 400% of the poverty line would receive federal subsidies to make such health insurance affordable.

The Medicaid expansion to cover all those with incomes of up to 133% of the poverty line was thus one of the building blocks in the ObamaCare reforms to enable all Americans to obtain access to affordable health care. Because of its historical origins in health care programs for the poor that had traditionally been implemented in the states, Medicaid is implemented at the state level even though it is funded jointly with the federal government. For the Medicaid expansion to 133% of the poverty line, the federal government through the legislation setting up ObamaCare committed to funding 100% of the incremental costs in the first three years (2014 to 2016) with this then phased down to 90% in 2020 and thereafter.

Despite this generous federal funding, the Supreme Court decided in 2012, in its decision that also found ObamaCare in general to be constitutional, that Congress could not force the states to expand Medicaid to the higher income limits. Thus the expansion became optional for the states, and as of April 2015, 21 states have decided not to. The 21 states are mostly in the south or the mountain west, with Republican legislatures and/or Republican governors or mostly both.

Blocking this Medicaid expansion in these states is being done even though an expansion would cost little or nothing. There is literally no state cost in the first three years as the federal government would cover 100% of the extra costs. And while the federal share would fall then to a still high 90% for 2020 and thereafter, allowing more of the poor to be covered by Medicaid will reduce state costs. The poor in this gap in coverage are forced to resort to expensive emergency room care, for which they cannot pay, when their health gets so bad that it cannot be ignored. These costs are then partially compensated by the state.

A careful analysis for Virginia, undertaken for the state by Price Waterhouse Coopers, concluded that if Virginia opted in to the Medicaid expansion, the state would save $601 million in state budget costs over the period 2014 to 2022. And this did not even include the indirect benefits to the budget from higher tax revenues, as a consequence of the additional jobs that would be created (nurses and other care providers, etc.) and the higher incomes of hospitals from less uncompensated care.

Denying affordable health care to the poor with incomes of between 100% and 133% of the poverty line is callous. These are the working poor, and there really is no excuse.

3) Ensure employers pay a proportionate share for health insurance for their part-time workers: Employers have traditionally not allowed part time employees to obtain (through their wage compensation package) health insurance cover in employer-based plans. There was a practical reason for this, as health insurance plans only provided cover in full. It has been difficult to provide partial plans, so part time workers have traditionally gotten nothing.

This has now changed with the introduction of the ObamaCare health insurance market exchanges. Those without health insurance coverage through their employers can now purchase a health insurance plan directly. One could therefore now require that all employers make a proportionate contribution to the cost of the health insurance plans for their part time workers. That is, for someone working half time (20 hours a week normally) the employer would contribute half of what that employer pays for the health insurance plans for their full time workers.

There would then be no incentive (and competitive advantage) for an employer to split a full time job with health insurance benefits into two half time jobs with no health insurance benefits for either worker. Under the current system of normally no health insurance benefits for part time workers, employer are in essence shifting the cost of health insurance fully onto the worker and onto the federal government (and hence general taxpayer) if the worker earns so little that they are eligible for federal government subsidies to purchase health insurance on the exchanges.

The proportional employer contribution would be paid to the “account” of the worker in the same way (and at the same time) as Social Security and Medicare taxes are paid for the worker. The funds from this account would then be used to cover part of the costs of the worker purchasing health insurance on the ObamaCare exchanges. And if the worker was working in two (and sometimes three or more) part time jobs in order to make ends meet, the total paid in from all of the worker’s employers might well suffice to cover the cost of the health insurance plan in full.

4) Allow competition from low cost public health insurance: As part of the political compromises necessary to get ObamaCare passed in the face of steadfast Republican opposition, only private health insurers are allowed to participate in the ObamaCare health insurance exchanges. Yet Medicare, which provides health insurance to all Americans age 65 and older, is far more efficient than private health insurance providers. Giving Americans the option (not a requirement) to purchase Medicare administered health insurance on the ObamaCare exchanges would introduce much needed competition. There are often only a few insurers competing in the exchanges, which are all state-based (3 or fewer insurers in 15 of the 51 states plus Washington, DC, with only one insurer offering policies in West Virginia).

But even with multiple insurers competing on the state exchanges, the private insurers in general have high costs. Private health insurers nationwide (and for all the policies they offer) have administrative costs plus profits equal to 14.0% of the health insurance benefits they pay out. This is huge. The same figure for Medicare is only 2.1%. Medicare costs only one-seventh as much to administer as private health insurance. And note these lower costs are not coming out of low payments to doctors and hospitals since the 14.0% and 2.1% are being measured relative to claims paid.

It would be straightforward to allow Medicare to compete on the health insurance exchanges. One would require that Medicare charge rates sufficient (for the resulting client base, which will of course be younger than and generally healthier than Medicare’s senior citizens) to recover its full costs for such coverage. But Medicare could use its existing administrative structure, including computer systems and contracts with doctors, hospitals, and other medical care providers at the rates that have already been negotiated.

Purchasing a Medicare administered health insurance policy on the exchanges would be fully optional. No one participating in the exchanges would be required to buy it. But with its lower costs, the competition Medicare would introduce into the exchanges could be highly effective in bringing down costs.

E. Pensions

Probably the greatest failure of any social experiment of recent decades has been the switch of employer pension plans from the traditional defined benefit plans that were common up to the early 1980s, to defined contribution schemes (such as 401(k) plans) that have grown to dominance since the 1980s. In doing this, employers not only shifted the investment, actuarial, and other risks on to the individual workers, but also typically reduced their matching funding shares significantly.

The end result is that workers are now typically woefully unprepared for retirement. The funds accumulated in their 401(k) and IRA accounts for households (with head of household aged 55 to 64) with a 401(k) account, only amounted to $111,000 in 2013 (for the median household). Such an accumulation, for households who will soon be in retirement, would suffice to provide only less than $400 a month by the traditional formulas, or $4,800 per year.

This is woefully inadequate, and these households will need to rely on what they can get from Social Security. But Social Security payments are also not much. For 2012 (the most recent year with such data), the median Social Security pension payment per beneficiary (age 65 or more) was just $16,799 per year, or per family unit (with head aged 65 or more) just $19,222 per year. Furthermore, if nothing is done, the Social Security Trust Fund will run down to a zero balance in 2033 based on the most recent projections.

Fully funding Social Security is eminently solvable, as will be discussed below. The annual cost (including for disability insurance) will rise from roughly 5% of GDP currently to 6% of GDP in 2030, as the baby boomers retire, or an increase of just 1% of GDP. But what many do not realize is that on current projections, Social Security expenditures are then expected to remain stable (under current benefit rules) at that 6% of GDP for the foreseeable future, in projections that go out 75 years. One can find 1% of GDP to save Social Security. But the politicians in Washington will need to agree to do so.

There are several measures that need to be taken to ensure income security for the poor and middle classes in their old age:

1) Raise, and certainly do not reduce, Social Security payments to those of low and modest income: Social Security payments, while a crucial safety net, are low. As noted above, the median payments in 2012 for those aged 65 and older were just $16,799 per beneficiary and $19,222 per recipient family (for the old age component). Such payments are minimal. Yet these are just medians, meaning half of all recipients received less than even those figures.

Despite being so low, these Social Security payments are critical to many Americans. For the entire population of those aged 65 and older, Social Security accounted for half or more of their total regular income for two-thirds of the population (65% to be precise); Social Security accounted for 90% or more of their income for over a third of the population (36%); and Social Security accounted for 100% of their income for a quarter of the population (24%). This is incredible, and shows the failure of the current pension systems in the US to provide a reasonable income in retirement for American workers.

The situation is, not surprisingly, worse for those of low to moderate income. For the bottom 40% of the population by income, where 40% is by far not a small or insignificant share, Social Security accounted for half or more of their regular total income for 95% of them. Social Security accounted for 90% or more of their income for three-quarters (74%) of them, and for 100% of their income for over half of them (53%).

Social Security benefits are by no means large. Yet a large share of Americans depend on them. They should not be cut, but rather should be raised, at least for those of low to moderate income who are critically dependent on them in their old age.

2) Broaden the base for Social Security taxes to ensure the system remains fully funded: As noted above, the Social Security Trust Fund will be depleted in 2033 (based on current projections, and including the disability component – while technically separate, the trust funds for old age and for disability insurance are normally treated together). While some argue, with some justification, that the Trust Fund is fundamentally just an accounting tool, which can be “topped-up” with regular federal government transfers if necessary, there are also good reasons to stay with the Trust Fund rules. They help keep the Social Security system out of routine Washington politics, and the temptation by conservatives to cut Social Security benefits in order to reduce the size of government.

Under the current Trust Fund rules, participation in the Social Security system is mandatory; taxes are paid on wage earnings (up to a ceiling of $118,500 in 2015); at a rate of 12.4% for Social Security pension and disability coverage for the employer and employee combined (excluding the 2.9% with no wage ceiling for Medicare); and upon retirement, these contributors will receive regular monthly payments from Social Security until they die, based on a formula which is linked to how much was paid into the Social Security Trust Fund during their working career (for the 35 years of highest inflation adjusted earnings). The formula is complex, and “tilted” in the sense that those earning less will receive back somewhat more than they paid in, while those earning in the upper end of the taxable range will receive back somewhat less. There is therefore some progressivity, but the degree of progressivity is limited. Finally, the taxes paid into the fund will earn interest at the rate of the long-term Treasury bond yield of the time, so the taxes paid in to the fund grow over time with interest.

Based on these Trust Fund rules and on current projections of growth in worker earnings (and its distribution) and of what pay-outs will be as workers retire, the Trust Fund is expected to be depleted in 2033. The basic cause is not that Social Security administration is inefficient and wasting funds. It is, in fact, incredibly efficient, with a cost of administration of just 0.5% of benefits paid out (on the old age component). Note this is not on assets, but on benefits paid. As will be discussed further below, the typical expenses on savings in 401(k) and similar accounts will be 2 to 3% of assets each and every year.

The principal cause of the Trust Fund being depleted, rather, is that life expectancies have lengthened, and hence the period over which Social Security old-age payments are made have grown. Crudely (and ignoring interest for this simple example), if life expectancy at age of retirement has grown by 50%, so that the number of years during which one will draw Social Security payments has grown by 50%, then the amount needed to be paid in to the Trust Fund to cover this lengthened life will need to grow by 50%.

Longer life expectancies are good. The Social Security Trust Fund will run out of assets in 2033 not because the funds are being wasted (as noted above, administrative costs are incredibly low), but because people are living longer. But this will need to be paid for.

But it is also critically important to recognize who is living longer. As incomes have stagnated for those other than the rich since Reagan took office (see the chart at the top of this post), life expectancies for the poor and middle classes have in fact not increased substantially. Rather, the overall life expectancy is rising principally because those at higher income levels are enjoying much longer life expectancies (in part precisely because their incomes have been growing so fast).

Specifically, life expectancy for a man at age 65 in the bottom half of earnings rose from 79.8 years in 1977 to 81.1 years in 2006, an increase of just 1.3 years. But life expectancy at age 65 for a man in the top half of earnings rose from 80.5 years in 1977 (only 0.7 years longer than men in the lower half of the earnings distribution in that year) to 86.5 years in 2006, an increase of 6.0 years. People are living longer, but it is mostly only those of higher income who are enjoying this. Life expectancies have not changed much for those of low to moderate income.

It would therefore be perverse to penalize those of lower income to make up for the Trust Fund shortfall, when it is the lengthening of the life spans of those of higher income which is leading to the depletion of the Trust Fund. Yet proposals to raise the retirement age, or to increase Social Security taxes on all, would charge the poor as much as the rich to make up for the Trust Fund deficit.

Rather than penalize the poor, Social Security taxes should be raised on those who are better off to pay for their increasing lifetime benefits. And this is of course also precisely what one should want to do if one is concerned about inequality.

The obvious solution is to broaden the tax base for the Social Security tax to include incomes now excluded – which are also incomes that accrue to the rich. First, note that the shortfall to be made up when the Social Security Trust Fund is expected to be depleted (if nothing is done) in the 2030s would require a 20% increase in revenues. That is, following a transition between now and about 2030 as the baby boomer generation retires, the long term projection is that Social Security tax and other revenues will level off at about 5% of GDP, while Social Security obligations will level off at about 6% of GDP. That is, we will need revenues to increase by about 20% to make up the shortfall, to get to 6% of GDP from 5%. (A more precise estimate, but from my blog post of a few years ago, is an increase of 19.4%).

Broadening the Social Security tax base would easily provide such an amount of funding. For wages alone, there is the current ceiling of $118,500 (in 2015) on wages subject to Social Security tax. At this ceiling, only 83% of all wages paid are subject to this tax. This is down from 89% in 1980 as an increasing share of wages are being paid to the very well off (those with wages above the ceiling). If one were to tax 100% of wages rather than only the current 83%, one would in fact obtain the funds needed, as that alone would provide an increase of over 20% (100/83 = 1.205).

But broadening the base should not stop at simply ensuring the taxes paying for Social Security are paid by all wage earners equally, rich and poor. There is no economic rationale why only wage income should be taxed for this purpose, and not also income from wealth. And income from wealth is primarily earned by the wealthy.

Using figures from the National Income and Product (GDP) accounts, total private income (including not just wages, but also income from interest, dividends, rents, and so on, but excluding government transfers) in 2014 was 65% more than just wages alone. (Note that while these income concepts from the GDP accounts are not the same as the income concepts defined in the income tax code, they suffice for the illustrative purposes here.) A uniform tax rate of 7.5% rather than 12.4% (12.4/7.5 = 1.65), but on all forms of income and not just wage income, would thus suffice to generate the Social Security tax revenues to fund fully the Trust Fund for the foreseeable future.

But one important proviso should be noted. Such tax rates (of either 12.4% on all wage income, or 7.5% on all forms of private income) would generate the revenues required to fully fund the system based on current benefit payment projections. However, with benefit payments tied to one’s history of tax payments, one would also need to change the benefit payment formulae to reflect the broader tax base. Otherwise the benefits due would also change to reflect the higher amounts paid in.

Finally, as noted above, current Social Security benefit payments are low and really need to be increased. While I do not have the data and models that would be required to work out fully some specific proposal, the figures here can give us a sense of what is possible. For example, a possible balance might be to broaden the tax base to include all forms of income, but then to reduce the tax rate on this not all the way from 12.4% to 7.5%, but rather to the halfway point of 10%. But this 10% rate would then suffice to permit a one-third increase in overall benefits (10/7.5 = 1.333), which one should want also to concentrate on those of low to moderate income. The overall tax rate would be cut, but in broadening the tax base to all forms of income one could support a significant increase in benefits. Overall taxes paid would be higher (everything has to add up, of course), and while low and moderate income earners would mostly see a reduction in the taxes they owe, richer individuals would pay more.

3) Require that 401(k) plan administration fees are paid for by the entity choosing the provider: Turning from Social Security to private pension plans, where defined contribution plans (401(k) plans and similar) are now the norm, the key issue is to keep fees low. Unfortunately they are extremely high, and take away a large share of the investment returns on the funds saved.

One cause of this is that the fees being received by the financial advisors are often hidden in various ways, and charged in different ways by different entities. There is no standard, and average levels are not made publicly available to provide a basis for comparison. The fees charged will also vary sharply depending on the type of investment product being used (i.e. direct equities, mutual funds of different types, insurance products including annuities, various complex products, and more). Finally, while individual fees might sometimes appear to be low, they are imposed at several layers in the investment process, and in total come to very high levels. Not surprisingly, according to one survey 93% of the respondents dramatically underestimated what their cumulative 401(k) fees will come to.

Estimates for what the average fees in fact now are vary. At the base will be the fees charged by a plan administrator, chosen by the firm of the employee and responsible for the record keeping, for allocating the investments as chosen by the plan participant, and so on. These fees will vary depending on the size of the firm and the deal negotiated on behalf of the employee, but one set of estimates are that these fees average 0.5% of plan assets annually in large firms (plan sizes of $100 million or more), 0.9% in medium size firms (plan assets of $10 million to $100 million) and 1.4% in small firms (plan assets of less than $10 million).

On top of these base administrative fees one will then have to pay the fees charged by the investment vehicles themselves. Mutual funds are perhaps most common, and the expense fees on these (normally subtracted from the investment returns, so the amount being paid will not be obvious) average about 1.1%. But they can range widely, from less than 0.1% for standard index funds, to over 2%. On top of this, one has the cost of buying and selling the investments (whether mutual funds or equities or the other products), which some estimate may average 1.0%. But these too can vary widely.

Finally, one may have individual fees on top of these all, which depend on the services being requested (whether investment advice, or entry and exit fees, or loan advances against balances in the worker’s pension accounts, and more). These will vary widely, but one estimate is that the median might be an annual cost of about 0.7% of assets.

The total amount lost in fees each year can therefore easily be in the range of 2 to 3% of assets, and 2.5% is a commonly taken average. Note also that these fees (or at least most of them) will be taken by the financial managers regardless of whether the investments perform well in any given year.

Over time, these fees will take for the financial administrators a large share of the investment returns that were intended for worker retirement. A simple spreadsheet calculation, for example, will show that over a 40 year time horizon, where (for simplicity) equal amounts are set aside each year for retirement, with an assumed 5% real rate of return but financial fees of 2.5% a year, the financial cost will have taken away by the 40th year 45% of what would otherwise be the balance saved. (It will not equal 50% because of the way compounding works.) This is 90 times the total fees that would be charged by Social Security for the old-age support it provides, which as noted above is only 0.5% of benefits paid out. Note that I am not arguing that the private fees should be the same as what the cost is for Social Security to administer the accounts. Social Security is an extremely efficient system. The specific share taken by financial fees will also depend, of course, on what is assumed for the rate of return and other parameters. But anything like 90 times as much is a lot.

Furthermore, many of the fees being charged on the private pension accounts will continue into the retirement years, so the final amount paid out in benefits will be even less. Assuming there will be 20 years of retirement following the 40 years of work, with returns and fees continuing as before, the annual amount that could be paid out to the worker in retirement will be only 44% of what would be paid out if the fees were at the 0.5% (of benefits only) of Social Security, a reduction of 56%!

Fees are therefore hugely important, but the worker can manage (through the decisions they make) only some of them. In particular, the basic plan administration fees for managing the accounts are made at the firm level. When firms had defined benefit pension plans, these costs were included in what the firm covered. They kept track of, or contracted out to some specialist, the individual payment obligations and other bookkeeping. But when firms switched to defined contribution schemes, most commonly 401(k)s, the firms chose to incorporate the costs of the plan administration into charges against the individual account balances, thus shifting these on to the workers. But the workers had no choice between plan administrators: They were chosen by the firm. And with the firm not bearing the cost, the firm might not worry so much about what the cost was. Rather, they might choose a plan administrator based on how good they were at making sales pitches, or whether they did other work for the firm where they might extend a discount, or based on who provided the fanciest annual conferences for their clients (the decision maker in the firm) at some resort in Hawaii.

Some firms of course make a sincere effort to choose the best balance between plan administrator cost and performance, but others do not. But to resolve this, a simple reform would be to require that firms pay the cost of plan administration directly from the firm’s accounts, and not out of the pension savings of the workers. This would return to what had normally been done with the traditional defined contribution pension plans, where firms had an incentive to ensure plan administration costs were kept low.

4) Require low cost investment options be included in 401(k) and similar schemes: One can also keep financial fees down by investing in low cost investment options, such as simple and standard index funds. The Vanguard S&P 500 Index Fund, and now even the Vanguard Total Stock Market Index Fund, each charge an annual expense fee of just 0.05%. This is far below the 1 to 2% charged by most managed mutual funds.

Such low cost options are included in many 401(k) plans, but unfortunately not all. Such options should be required in all.

5) Provide an option of investing in “Social Security Supplemental Accounts”: One very low cost investment option would be to invest a portion of one’s 401(k), IRA, and similar balances, into a supplemental account managed by Social Security, which would then be paid out along with one’s regular Social Security checks. Accounts would earn a return equal to the long-term US Treasury bond rate, the same as existing Social Security balances do now. The option would take advantage of the extremely high efficiency of the Social Security Administration.

With the far lower cost of Social Security relative to what private financial institutions in the US charge, the net return on such investments would be attractive. Given historical long term bond interest rates and the differences in fees, the returns would be comparable to what might be earned in pure equity investments, but far less volatile. And the returns would be far better than what on average has been earned in actual 401(k) and IRA accounts, given how they have historically been managed.

The Social Security Supplemental Account would be purely voluntary. No one would be forced to put a share of their 401(k) or IRA assets into them. But this would be an attractive option for at least a share of the plan assets, earning a comparable return (after fees) but with far less risk. It would be especially attractive to middle class families who may have significant but not huge assets in their retirement accounts, who are seeking to ensure a safe retirement.

F. Conclusion

The returns to economic growth have become horribly skewed since Reagan took office, but there is much that could be done to address it. This blog post has discussed a number of actions that could be taken, and if the Republican (and Democratic) candidates are truly concerned about the direction of income inequality, there is no shortage of measures to consider. And this is not an all or nothing set of actions: While complementary and mutually reinforcing, taking some actions is better than none, and more is better than some. Nor are they in general administratively difficult to do. Most are straightforward.

The Affordable Care Act (ACA, and also often referred to as ObamaCare) has been working well by any objective measure. There are now more than 10 million additional Americans who have health insurance who could not get affordable health care before; the share of the uninsured in the US population is now a quarter less than what it was before the individual mandate of the Affordable Care Act went into effect; and this has been achieved at premium rates for the new plans that are reasonable and well less than opponents charged they would be. Health care costs have also stabilized under Obama, both as a share of GDP and in terms of health prices relative to overall prices, in contrast to the relentless increases in both before. And while some have criticized this, it is good that there are now minimum quality and coverage standards in health insurance plans. Such standards are good in themselves. And without such standards, purported health care “plans” which offer next to nothing (due, for example, to extremely high deductibles) and which can then cost next to nothing, would lead to a death spiral for genuine health care plans that cover costs when you are sick and need treatment.

Gains from the ACA are also reflected in the findings of a recently published report from The Commonwealth Fund. The Commonwealth Fund has been organizing a periodic survey on health care coverage since 2001. The most recent survey (for 2014) found that for the first time since the question was first asked in 2003, there was a reduction in the number of Americans avoiding (because of cost) health care services that they needed. And for the first time since the question was first asked in 2005, the number reporting medical bill or debt problems also fell. Personal financial distress due to medical problems has been reduced, due to greater access to health insurance and due to health insurance plans that now meet minimum standards.

Despite this (but not surprisingly given the position they staked out against the reform), the Republican Congress continues to vote to repeal, or at least weaken, the law. The most recent vote was aimed at the provision in the Act which complements the individual mandate to purchase health insurance, with an employer mandate requiring firms with 100 full time equivalent employees or more from January 1 of this year (and with 50 or more from January 1, 2016) to offer health insurance to their full time employees or pay a fee. The proposed Republican bill would change the definition of a full time worker from one who normally works 30 hours or more a week, to one who works 40 hours or more a week.

The supporters of the change charge that the prospect that employers (with 50 or 100 employees or more) will soon be required to offer health insurance to their full time employees has led firms to cut working hours of their employees, to shift them from full time to part time status, and hence avoid the employer mandate of the ACA. As a Republican congressman from Texas said: “We have heard story after story from every state in the union that employers are dropping workers’ hours from less than 39 hours a week to perhaps less than 29.”

This accusation is confused on several levels. This post will first look at whether there is in fact any evidence that workers are being shifted from full time to part time status as a result of the ACA (or indeed for any other reason). The answer is no, at least at the level of the overall economy. Second, there has been a good deal of confusion in the discussion on what the issue really is with regard to part time workers, including by prominent congressmen such as Paul Ryan. Either Ryan does not understand what the employer mandate is, or if he does, then he has deliberately mischaracterized it.

The public discussion has also avoided altogether the real issue. It is not that firms with 50 workers or more would be required to offer health insurance to their employees (most do already), but that this insurance is only made available to their full time workers. Part time workers get nothing, no matter what size firm they work at. The final section of this blog post will discuss a way to resolve this equitably.

B. What is the Evidence on Whether the ACA Has Increased the Ranks of Part Time Workers?

The opponents of ObamaCare assert that as a result of the employer mandate, firms have been shifting workers from full time to part time status. E.g., instead of employing one worker for 40 hours, they are choosing to employ two workers for 20 hours each. If true, the ratio of part time workers to the total employed will rise.

The chart at the top of this post shows this has not been the case. It is based on data from the Bureau of Labor Statistics, from its Current Population Survey. This monthly survey of households is used to determine the unemployment rate among other statistics. The households surveyed are asked whether household members are employed full time or part time (if employed), and if part time, whether this is by choice (because they only want to work part time) or because they want a full time job but cannot find one. The chart above shows the ratio of workers who are working part time not by choice but for economic reasons, to all workers employed. Note that the BLS data defines a part time worker as one with fewer than 35 hours of work per week. While this differs from the 30 hour standard in the ACA, as well as the 40 hour standard in the recently passed Republican legislation, the results in terms of the trends should be similar. The BLS does not publish data with a different cutoff in terms of hours per week for what is considered part time work.

As in any economic downturn, the ratio rose rapidly in the economic collapse of the last year of the Bush administration. Regular jobs were disappearing, with some of them shifting to part time status. Indeed, the absolute number of part time jobs was increasing at the time, even as the total number of jobs was falling, thus leading to two reasons for the ratio to rise, and rise rapidly.

The ratio reached a peak soon after Obama took office, and began to fall about a year later. Since then it has fallen at a fairly steady pace in terms of the trend. There were sometimes relatively sharp month to month fluctuations in the data, but this can be on account of statistical noise. The data comes from a limited sample of households, with only 5 to 6% or so of those employed on part time status (for economic reasons) for most of this period, so the statistical noise in a relative sense (month to month) will be large. But the downward trend over time is clear, and at a similar downward pace for close to five years now.

What one does not see is any shift in this downward trend linked either to the signing of the Affordable Care Act in March 2010, or to the start of the individual health insurance mandate in January 2014, or to the anticipation of the start of the employer health insurance mandate in January 2015. Note that since the classification of a worker as a full time or part time worker (and hence the classification of the firm as crossing the 100 or 50 full time worker standard) will be in a period of up to 12 months before the employer mandate goes into effect, one would have seen an impact in 2014 if the 2015 mandate mattered. There is no indication of this.

The data cover the overall economy. The figures refer to millions of workers as well as millions of employers. The US is a large place. Within such a large place, it will undoubtedly be possible to find particular cases where employers will say that they reduced worker hours to part time status so that they could avoid the health insurance employer mandate. And one could indeed probably find a long list of firms making such statements. It would be even easier to find a long list of firms and other entities where working hours were cut, whether or not there was any employer mandate pending. In a dynamic economy, there will always be a large number of such cases (along with a large number of cases of firms going in the opposite direction, converting part time jobs to full time jobs).

Such anecdotal information, and even a long list of such anecdotes, is not evidence of an issue of substantial scale. As seen above, there is no evidence of it in the overall numbers. But one should still recognize that the issue could exist in particular cases. The question, however, is what is the real issue here, and if there is one, how can it be addressed.

C. What the Employer Health Insurance Mandate Says

For better or worse, the US health care insurance system is built around health plans normally provided to workers through their place of employment, as part of their overall wage compensation package. The system began during World War II and has expanded since, supported through substantial tax advantages. By now, health insurance provision is close to universal among large employers, but substantially less so among small private firms:

Overall, 84.9% of private sector employees are in firms that offer health insurance as part of their wage packages. And 96% of firms with more than just 50 employees offer health insurance.

The Affordable Care Act built on this and did not replace it. Liberals (including myself) would have preferred moving to a system where Medicare would be extended to cover the entire population rather than just those over age 65. Medicare is an efficient and well managed program, and as an earlier post in this blog discussed, its administrative expenses come to only 2.1% of the benefits paid. In contrast, administrative costs (including profits) of private health insurance are seven times higher at 14.0% of benefits paid, and an even higher 18.6% of benefits paid in the privately administered Medicare Advantage plans.

But Obama agreed instead to support an approach first proposed by the conservative Heritage Foundation, which was then put forward by Republicans in Congress as their alternative to the health reforms proposed by the Clinton administration (coming out of the task force Hillary Clinton chaired), and which was later adopted in Massachusetts when Mitt Romney was governor. These plans were built around keeping the existing employer-based provision of health insurance for most of those employed, but to complement this with markets where individuals could purchase health insurance directly if they did not have employer-based coverage, coupled with an individual mandate to buy such health insurance. The individual mandate is necessary to counter what would otherwise be a resulting death spiral of health insurance plans if everyone is granted access (including those with pre-existing conditions) but only the sick then purchased health insurance (for a description and discussion, see this earlier Econ 101 blog post).

It was not unreasonable to believe that the Republicans would not oppose a plan whose origins lies in their own earlier proposals, but that was not to be.

As noted, the individual mandate is necessary to avoid death spirals in health insurance plans for individuals. Complementing this, an employer mandate to offer health insurance to their employees is necessary to counter what could otherwise be a “race to the bottom”. If certain firms did not support such health insurance for their employees, thus reducing the cost to them of their workers, they could undercut competitors who did provide good health insurance support. It could lead to a race to the bottom. While not yet widespread in the US, especially for larger firms (see the table above), there has been increasing competitive pressure in the US over the last couple of decades to cut such health insurance support. An increasing number of employers have done so.

Thus the ACA includes an employer mandate to complement the individual mandate. However, while the individual mandate went into effect on January 1, 2014, the employer mandate has been twice delayed, and has now (as of January 1, 2015) gone into effect for firms employing 100 of more full time equivalent employees, and will go into effect on January 1, 2016, for firms employing 50 or more full time equivalent employees. It is this provision that the Republicans in Congress are now trying to subvert.

The charge by Paul Ryan and others has been that medium to small size firms have been cutting the hours of their employees to shift the workers from a full-time classification to a part-time one. The aim, they say, has been to reduce the number of their full time workers to below 50 so as to avoid the employer mandate. For example, in a recent opinion piece published in USA Today, Congressman Ryan wrote: “The law requires employers with more than 50 full-time employees to give them health insurance. But because the law defines “full time” as 30 hours or more, employers are keeping employees below that threshold to avoid the mandate entirely.”

However, that is not what the law says. Precisely to avoid such an incentive, the boundaries on the size of a firm subject to the employer mandate is defined in terms of full time equivalent workers (whether 50 or 100). That is, if a job is split from one full time worker to two half time workers, the number of full time equivalent workers is unchanged. The two half time workers count as one full time worker for the purposes of the statute. Cutting back on the number of hours of individual workers to make them part time will not change the status of the firm when the total hours of labor to produce whatever the firm is producing remains unchanged. And it would be foolish for a firm to produce and sell less when the demand exists for such sales, simply to avoid this mandate.

There is, however, a critically important issue here which Ryan and his colleagues have not discussed. While splitting jobs of full time workers into multiple part time jobs will not change the status of the firm on whether it is subject to the employer mandate, shifting workers from full time to part time status does affect whether the firm would be required to include health insurance as part of their wage compensation package. Firms subject to the mandate must offer an affordable health insurance plan available to at least 95% of full time (not full time equivalent) workers, or pay a fee. The fee (of up to $2,000 per year per worker, less 30 workers per firm) is designed to partially offset (and only very partially offset) the cost of health insurance that they are shifting to others.

But such health insurance typically only is provided to full time workers. This is true even for giant corporations. Hence a firm can avoid making health insurance available to its workers by shifting them from full time to part time status. This has always been the case, and is indeed a problem.

The Affordable Care Act addresses the issue only partially and tangentially. By including a definition of what constitutes full time work at 30 hours a week or more, the ACA reduces the incentive to shift workers from the traditional 40 hours per week for full time work, to just under 40 hours in order to avoid providing health insurance cover. A firm would need to cut a normal worker’s hours to below 30 hours per week to avoid providing health insurance, and is unlikely to do that for its regular work force. But by moving the dividing line up to 40 hours per week, as the Republican legislation passed on January 8 would do, one opens up a loophole for firms to reduce worker hours from 40 to say 39 per week (or 39 1/2 or even 39.99 I would suppose). Firms would be able easily to avoid offering health insurance to what are in reality their regular, full time, workers; use this to undercut competitors who do offer such insurance; and thus spark a race to the bottom on health insurance coverage in those industries.

D. Addressing the Problem of Health Insurance for Part Time Workers

As noted above, the ACA does not do much to address the problem of part time workers receiving nothing from their employers for the health insurance everyone needs. Setting the floor at 30 hours per week helps by ensuring workers close to the traditional 40 hour workweek will receive an employer contribution to their health insurance, and avoids the incentive to shift workers from 40 hours per week to just a bit below. But part time workers of less than 30 hours per week will still normally receive nothing from their employer to help cover their health insurance. And it creates an incentive for employers to structure positions as two workers at 20 hours per week, say, than one at 40. While whether or not the firm was subject to the employer mandate would not be affected (since it is expressed in terms of full time equivalent workers), whether or not the firms would need to provide anything in terms of health insurance would be affected.

But there is a way to address this, now that the individual health insurance marketplaces are operational under the ACA. All firms could be required to contribute an amount for their part time workers proportional to the hours of such part time work to what full time work would be. That is, if two workers are each working half time, the firm would contribute an amount of 50% (for each) of the cost of the employer contribution to the health insurance for one full time worker. The total cost would be the same whether the firm employed one full time or two half time workers. There would also then not be an incentive to split jobs from full time workers to multiple part time workers.

The employer contribution to the part time worker’s health insurance costs would then be paid, along with taxes such as for Social Security or Medicare, to the government in the name of the specific part time worker. These funds would then be used as a partial pay down of the costs of that worker purchasing health insurance on the individual health insurance market exchanges set up under the ACA. And while other splits could be considered, I would recommend that those funds would be split half and half between what the worker would need to pay on the exchange for his or her health plan, and what the government subsidy would provide.

A simple numerical example may help clarify this. Using made up numbers, suppose the full monthly cost of a standard (Silver level) health insurance plan on the individual exchange where the worker resides is $400. Assume also that at the current income level of this (part time) worker, the government subsidy for such insurance would be $200 per month, while the worker would pay $200 per month. Now assume that firms would be required to pay proportional shares of what they provide to full time workers for their health insurance, and that this would come to $100 per month for this part time worker. This would be split half and half between what the government subsidy would be and what the worker would pay, so under the new approach the government would provide $150, the worker would pay $150, and the funds coming from the firm would cover $100, summing to the $400 total cost.

A few specifics to note: Many part time workers hold down multiple jobs. They would receive for their “account” the total proportional amounts from all of their employers. Many part time workers are also part of married couples. There could be a household account into which all the sums were paid (for each family member), which could be used to purchase a family health plan on the exchanges. In the event that the family was not purchasing insurance through the exchange (perhaps, for example, because the spouse worked at a firm providing family coverage), the amount paid by the firm for the part time worker would be returned to the firm (or canceled from the start).

And if the total amounts paid in from the full set of employers for that individual (or family) led to the government subsidy falling all the way to zero, any excess would be allocated to what the individual would pay for the insurance. This could be common in cases where the family income of the part time worker was close to, or above, the income limit on which government subsidies are provided.

It is only with the advent of the individual health insurance exchanges that this method for covering part time workers became possible. Previously, firms were not in a position to purchase half of an insurance policy for a half time worker. But now they can contribute an amount equal to half the cost, with this then used to help purchase coverage on the individual marketplace exchanges.

Note also that with this reform, it would matter less whether full time work was defined as 30 hours per week or 40 hours per week or whatever. I would recommend keeping the 30 hour per week boundary as it would be a factor in determining what the employer contribution would be. But it would not be as critical as now, where the boundary determines whether 100% of the employer share of the health insurance cost is paid or 0% is paid. There would be a smooth transition (a worker of 39 hours when 40 hours is defined as the standard would still receive 39/40 of the payment, and not zero), without a drop straight to zero.

There would also be no reason to limit this extension of the employer mandate only to firms with 50 (or 100) or more full time equivalent workers. All firms should make such a contribution to covering the cost of their workers’ health insurance needs, just as they all make a contribution to Social Security and Medicare taxes. Indeed firms of whatever size (although this will soon apply only to firms with less than 50 full time equivalent workers) that do not have any health insurance plan for their staff should participate. The amounts paid could be set as a proportion to the cost of the medium Silver level plan available on the individual health insurance exchanges in their area.

Undoubtedly, there will be assertions by the Republicans that requiring such a contribution to health insurance costs for their part time workers will lead to an end to such jobs. This would be similar to the arguments they have made that raising the minimum wage will lead to higher unemployment of lower paid workers, and arguments that were made earlier that paying Social Security taxes would lead to higher unemployment. But as was discussed in an earlier blog post, there is no evidence that increases in the minimum wage in the magnitudes that have been discussed have led to such higher unemployment. Ensuring firms contribute proportionally to the health insurance costs of their part time workers would not either.

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